drug abuse

CH

AP

TE

R Substance Abuse and Dependence

CHAPTER OUTLINECLASSIFICATION OF SUBSTANCE-RELATEDDISORDERS 291–296Substance Abuse and DependenceAddiction and Other Forms of Compulsive

BehaviorRacial and Ethnic Differences in Substance

Use DisordersPathways to Drug Dependence

DRUGS OF ABUSE 296–310DepressantsStimulantsHallucinogens

Residential ApproachesPsychodynamic ApproachesBehavioral ApproachesRelapse-Prevention Training

SUMMING UP 325–326

THEORETICAL PERSPECTIVES 310–316Biological PerspectivesLearning PerspectivesCognitive PerspectivesPsychodynamic PerspectivesSociocultural Perspectives

TREATMENT OF SUBSTANCE ABUSE AND DEPENDENCE 316–325Biological ApproachesCulturally Sensitive Treatment

of AlcoholismNonprofessional Support Groups

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291

or

T❑ F❑ Heroin accounts for more deathsthan any other drug. (p. 291)

T❑ F❑ You cannot be psychologicallydependent on a drug without also beingphysically dependent on it. (p. 295)

T❑ F❑ More teenagers and young adults diefrom alcohol-related motor vehicle accidentsthan from any other cause. (p. 297)

T❑ F❑ It is safe to let someone who haspassed out from drinking just “sleep it off.”(p. 301)

T❑ F❑ Even moderate use of alcoholincreases the risk of heart attacks. (p. 303)

T❑ F❑ Coca-Cola originally containedcocaine. (p. 306)

T❑ F❑ Breast cancer is the leading cause ofcancer deaths among U.S. women. (p. 307)

T❑ F❑ People who can “hold their liquor”better than most stand a lower risk ofbecoming problem drinkers. (p. 312)

T❑ F❑ A widely used treatment for heroinaddiction involves substituting anotheraddictive drug. (p. 318)

or

“Nothing and Nobody Comes Before My Coke”She had just caught me with cocaine again after I had managed to convince her thatI hadn’t used in over a month. Of course I had been tooting (snorting) almost everyday, but I had managed to cover my tracks a little better than usual. So she said tome that I was going to have to make a choice—either cocaine or her. Before shefinished the sentence, I knew what was coming, so I told her to think carefully aboutwhat she was going to say. It was clear to me that there wasn’t a choice. I love mywife, but I’m not going to choose anything over cocaine. It’s sick, but that’s whatthings have come to. Nothing and nobody comes before my coke.

—From Weiss & Mirin, 1987, p. 55

THESE COMMENTS FROM EUGENE, A 41-YEAR-OLD ARCHITECT, UNDERSCORE THE POWERFUL

effects that drugs like cocaine can have on people’s lives. Our society is flooded withpsychoactive substances that alter the mood and twist perceptions—substances thatlift you up, calm you down, and turn you upside down. Many young people start usingthese substances because of peer pressure or because their parents and other authorityfigures tell them not to. For Eugene, as for many others who become addicted to drugs,the pursuit and use of drugs takes center stage in their lives and becomes even moreimportant than family, work, or their own welfare.

In this chapter we examine the physiological and psychological effects of the majorclasses of drugs. We explore how mental health professionals classify substance-relateddisorders and where we draw the line between use and abuse. We then examine con-temporary understandings of the origins of these disorders and how mental healthprofessionals help people who struggle to combat them.

CLASSIFICATION OF SUBSTANCE-RELATED DISORDERSUnder certain conditions, the use of substances that affect mood and behavior is normal,at least as gauged by statistical frequency and social standards. It is normal to start theday with caffeine in the form of coffee or tea, to take wine or coffee with meals, to meetfriends for a drink after work, and to end the day with a nightcap. Many of us take pre-scription drugs that calm us down or ease our pain. Flooding the bloodstream withnicotine by means of smoking is normal in the sense that about 1 in 5 Americans do it.However, some psychoactive substances, such as cocaine, marijuana, and heroin, are ille-gal and are used illicitly. Others, such as antianxiety drugs (such as Valium and Xanax)and amphetamines (such as Ritalin), are available by prescription for legitimate medicaluses. Still others, such as tobacco (which contains nicotine, a mild stimulant) and alco-hol (a depressant), are available without prescription, or over-the-counter. Ironically, themost widely and easily accessible substances—tobacco and alcohol—cause more deathsthrough sickness and accidents than all illicit drugs combined.

The classification of substance-related disorders in the DSM system is not based onwhether a drug is legal or not, but rather on how drug use impairs the person’s physio-logical and psychological functioning. The DSM-IV classifies substance-related disordersinto two major categories: substance use disorders and substance-induced disorders.

Substance-induced disorders are disorders induced by using psychoactive substances,such as intoxication, withdrawal syndromes, mood disorders, delirium, dementia, amne-sia, psychotic disorders, anxiety disorders, sexual dysfunctions, and sleep disorders.Different substances have different effects, so some of these disorders may be induced byone, a few, or nearly all substances. Let us consider the example of intoxication.

T R U T H F I C T I O N

Heroin accounts for more deaths than any otherdrug.

❑ FALSE. Two legally available substances,alcohol and tobacco, cause far more deaths.✓

F I C T I O NT R U T H or

substance-induced disorders Disorders,such as intoxication, that can be induced byusing psychoactive substances.

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Two of the many faces of alcohol use—and abuse. Alcohol is our most widely used—andabused—drug. Many people use alcohol to celebrate achievements and happy occasions, as inthe photograph on the left. Unfortunately, like the man in the photograph on the right, somepeople use alcohol to drown their sorrows, which may only compound their problems. Whereexactly does substance use end and abuse begin? According to the DSM, use becomes abusewhen it leads to damaging consequences.

intoxication A state of drunkenness.

substance use disorders Disorders chararacterized by maladaptive use of psychoactive substances (e.g., substancedependence).

substance abuse The continued use of apsychoactive drug despite the knowledgethat it is causing a social, occupational, psychological, or physical problem.

substance dependence Impaired controlover the use of a psychoactive substance; oftencharacterized by physiological dependence.

Substance intoxication refers to a state of drunkenness or being “high.” This effectlargely reflects the chemical actions of the psychoactive substances. The particular fea-tures of intoxication depend on which drug is ingested, the dose, the user’s biologicalreactivity, and—to some degree—the user’s expectations. Signs of intoxication ofteninclude confusion, belligerence, impaired judgment, inattention, and impaired motorand spatial skills. Extreme intoxication from use of alcohol, cocaine, opioids, (nar-cotics) and PCP can even result in death (yes, you can die from alcohol overdoses),either because of the substance’s biochemical effects or because of behavior patterns—such as suicide—that are connected with psychological pain or impaired judgmentbrought on by use of the drug.

Substance use disorders are patterns of maladaptive use of psychoactive sub-stances. These disorders, which include substance abuse and substance dependence, arethe major focus of our study.

Substance Abuse and DependenceWhere does substance use end and abuse begin? According to the DSM, substanceabuse is a pattern of recurrent use that leads to damaging consequences. Damagingconsequences may involve failure to meet one’s major role responsibilities (e.g., as stu-dent, worker, or parent), putting oneself in situations where substance use is physicallydangerous (e.g., mixing driving and substance use), encountering repeated problemswith the law arising from substance use (e.g., multiple arrests for substance-relatedbehavior), or having recurring social or interpersonal problems because of substanceuse (e.g., repeatedly getting into fights when drinking).

When people repeatedly miss school or work because they are drunk or “sleeping itoff,” their behavior may fit the definition of substance abuse. A single incident of exces-sive drinking at a friend’s wedding would not qualify. Nor would regular consumptionof low to moderate amounts of alcohol be considered abusive so long as it is not con-nected with any impairment in functioning. Neither the amount nor the type of drugingested, nor whether the drug is illicit, is the key to defining substance abuse accord-ing to the DSM. Rather, the determining feature of substance abuse is whether a pat-tern of drug-using behavior becomes repeatedly linked to damaging consequences.

Substance abuse may continue for a long period of time or progress to substancedependence, a more severe disorder associated with physiological signs of dependence(tolerance or withdrawal syndrome) or compulsive use of a substance. People who

Substance Abuse and Dependence 293

tolerance Physical habituation to a drugsuch that with frequent use, higher doses areneeded to achieve the same effects.

withdrawal syndrome A characteristiccluster of symptoms following the suddenreduction or cessation of use of a psychoactivesubstance after physiological dependence hasdeveloped.

become compulsive users lack control over their drug use. They may be aware of howtheir drug use is disrupting their lives or damaging their health, but feel helpless orpowerless to stop using drugs, even though they may want to. By the time they becomedependent on a given drug, they’ve given over much of their lives to obtaining andusing it. The cocaine user whose words opened this chapter would certainly fit this def-inition. The diagnostic features of substance dependence are listed in Table 9.1.

Repeated use of a substance may alter the body’s physiological reactions, leading tothe development of tolerance or a physical withdrawal syndrome (see Table 9.1).Tolerance is a state of physical habituation to a drug, resulting from frequent use, suchthat higher doses are needed to achieve the same effect. A withdrawal syndrome (alsocalled an abstinence syndrome) is a cluster of symptoms that occur when a dependentperson abruptly stops using a particular substance following heavy, prolonged use.People who experience a withdrawal syndrome often return to using the substance torelieve the discomfort associated with withdrawal, which thus serves to maintain theaddictive pattern. Withdrawal symptoms vary with the particular type of drug. Withalcohol dependence, typical withdrawal symptoms include dryness in the mouth,nausea or vomiting, weakness, increased heart rate, anxiety, depression, headaches,insomnia, elevated blood pressure, and fleeting hallucinations.

In some cases of chronic alcoholism, withdrawal produces a state of delirium tremens,or DTs. DTs are usually limited to chronic, heavy users of alcohol who dramatically lowertheir intake of alcohol after many years of heavy drinking. DTs involve intense autonomichyperactivity (profuse sweating and tachycardia) and delirium—a state of mental confu-sion characterized by incoherent speech, disorientation, and extreme restlessness.Terrifying hallucinations—frequently of creepy, crawling animals—may also be present.

Substances that may lead to withdrawal syndromes include—in addition toalcohol—opioids, cocaine, amphetamines, sedatives and barbiturates, nicotine, and

T A B L E 9 . 1

Diagnostic Features of Substance DependenceSubstance dependence is defined as a maladaptive pattern of use that results in significantimpairment or distress, as shown by the following features occurring within the same year:

1. Tolerance for the substance, as shown by eithera. the need for increased amounts of the substance to achieve the desired effect or

intoxication, orb. marked reduction in the effects of continuing to ingest the same amounts.

2. Withdrawal symptoms, as shown by eithera. the withdrawal syndrome that is considered characteristic for the substance, orb. the taking of the same substance (or a closely related substance, as when methadone is

substituted for heroin) to relieve or to prevent withdrawal symptoms.3. Taking larger amounts of the substance or for longer periods of time than the individual

intended (e.g., person had desired to take only one drink, but after taking the first,continues drinking until severely intoxicated).

4. Persistent desire to cut down or control intake of substance or lack of success in trying toexercise self-control.

5. Spending a good deal of time in activities directed toward obtaining the substance (e.g., visiting several physicians to obtain prescriptions or engaging in theft), in actuallyingesting the substance, or in recovering from its use. In severe cases, the individual’sdaily life revolves around substance use.

6. The individual has reduced or given up important social, occupational, or recreationalactivities due to substance use (e.g., person withdraws from family events in order toindulge in drug use).

7. Substance use is continued despite evidence of persistent or recurrent psychological orphysical problems either caused or exacerbated by its use (e.g., repeated arrests for drivingwhile intoxicated).

Note: Not all of these features need be present for a diagnosis to be made.

Source: Adapted from the DSM-IV-TR (APA, 2000).

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Per

cent

age

with

Dru

g D

epen

den

ce

2.5

2

1.5

1

0.5

0Opioid Amphetamine Cocaine Marijuana Any Drug

Dependence

FIGURE 9.1 Lifetime prevalence of drugdependence disorder by type of illicit drug.Drug dependence disorders involving illicitdrugs affect nearly 3 in 100 adults in theUnited States. Marijuana (cannabis) depend-ence is the most common type.

Source: Conway et al., 2006.

addiction Impaired control over the use of a chemical substance, accompanied byphysiological dependence.

physiological dependence A condition inwhich the drug user’s body comes to dependon a steady supply of the substance.

antianxiety agents (minor tranquilizers). Marijuana and hallucinogens such as LSD arenot recognized as producing a withdrawal syndrome, because abrupt withdrawal fromthese substances does not produce clinically significant withdrawal effects (APA, 2000).

Substance dependence is often, but not always, associated with the development ofphysiological dependence. It sometimes involves a pattern of compulsive use withoutphysiological or chemical dependence. For example, people may become compulsiveusers of marijuana, especially when they rely on the drug to help them cope with thestresses of daily life. Yet they may not require larger amounts of the substance to get“high” or experience distressing withdrawal symptoms when they cease using it. In mostcases, however, substance dependence and physiological features of dependence occurtogether. Despite the fact that the DSM considers substance abuse and dependence tobe distinct diagnostic categories, the borderline between the two is not always clear.

Unfortunately, substance abuse and dependence disorders are common problems inour society (Adelson, 2006). An estimated 10.3% of adults in the United States developdrug (substance) use disorders on an illicit drug at some point in their lives, with about7.7% developing a drug abuse disorder and about 2.5% developing a drug dependencedisorder (Compton et al., 2005). About 8% of adult Americans develop alcohol abuseor dependence disorders (Lemonick, 2007). People with one drug use disorder, such asalcohol dependence disorder, often present with another, such as cocaine dependencedisorder (Stinson et al., 2005). In Figure 9.1 we see the percentages of U.S. adults whodevelop drug dependence disorders on various types of illicit drugs.

Addiction and Other Forms of Compulsive BehaviorThe DSM uses the terms substance abuse and substance dependence as categories of sub-stance use disorders. It does not use the term addiction to describe these problems. Yet theconcept of addiction is widespread among professionals and laypeople alike. Even someleading professionals believe the word “addiction”should replace the word “dependence” inthe diagnostic manual (O’Brien, Volkow, & Li, 2006). But what does the term “addiction”mean? Before we proceed to discuss drugs of abuse, let us define the terms we will be using.

We lack any universally accepted definition of addiction. For our purposes, wedefine addiction as compulsive use of a drug accompanied by signs of physiologicaldependence. People become compulsive users when they have impaired control overtheir use of a drug. In effect, they feel compelled to continue using the drug despite thenegative consequences that continued use of the drug entails. By physiologicaldependence, we mean that a person’s body has changed as a result of the regular useof a psychoactive drug in such a way that it comes to depend on having a steady supplyof the substance. The major signs of physiological dependence are the development oftolerance and a withdrawal syndrome.


psychological dependence Compulsiveuse of a substance to meet a psychologicalneed.

People can also develop psychological dependence on a drug without becomingphysiologically or chemically dependent. These individuals come to compulsively usea drug to meet psychological needs. We can think of someone who compulsively usesmarijuana to cope with daily stress, but is not physiologically dependent on the drug.On the other hand, a person may become physiologically dependent on a drug but notbecome a compulsive user. For example, people recuperating from surgery are oftengiven narcotics derived from opium as painkillers. Some develop signs of physiologi-cal dependence, such as tolerance and a withdrawal syndrome, but do not developimpaired control over the use of these drugs.

Other forms of compulsive behavior, such as compulsive gambling, shopping, oreven Internet use, can be likened to forms of nonchemical addiction. Whether we labelsuch behavioral patterns as addictions depends on how we define the concept of addic-tion (see Chapter 13 for a discussion of compulsive gambling). In this chapter, wefocus on chemical forms of dependence.

Racial and Ethnic Differences in Substance Use DisordersDespite the popular stereotype that drug dependence is more frequent among ethnicminorities, this belief is not supported by evidence. To the contrary, African Americans andLatinos have comparable or even lower rates of substance use disorders than do EuropeanAmericans (non-Hispanic Whites) (Breslau et al., 2005; Compton et al., 2005). Moreover,African American adolescents are much less likely than European American adolescents todevelop substance abuse or dependence problems (Kilpatrick et al., 2000). In a later sectionwe shall examine evidence on racial/ethnic group differences in alcohol use and abuse.

Pathways to Drug DependenceAlthough the progression to substance dependence varies from person to person,one common pathway involves a progression through the following stages (Weiss &Mirin, 1987):

1. Experimentation. During the stage of experimentation, or occasional use, thedrug temporarily makes users feel good, even euphoric. Users feel in control andbelieve they can stop at any time.

2. Routine use. During the next stage, a period of routine use, people begin to struc-ture their lives around the pursuit and use of drugs. Denial plays a major role atthis stage, as users mask the negative consequences of their behavior to themselvesand others. Values change. What had formerly been important, such as family andwork, comes to matter less than the drugs.

The following clinical interview illustrates how denial can mask reality. This48-year-old executive was brought for a consultation by his wife. She complainedhis once-successful business was jeopardized by his erratic behavior, he wasgrouchy and moody, and he had spent $7,000 in the previous month on cocaine.

CLINICIAN: Have you missed many days at work recently?EXECUTIVE: Yes, but I can afford to, since I own the business. Nobody checks up on me.CLINICIAN: It sounds like that’s precisely the problem. When you don’t go to work,

the company stays open, but it doesn’t do very well.EXECUTIVE: My employees are well trained. They can run the company without me.CLINICIAN: But that’s not happening.EXECUTIVE: Then there’s something wrong with them. I’ll have to look into it.CLINICIAN: It sounds as if there’s something wrong with you, but you don’t want to

look into it.EXECUTIVE: Now you’re on my case. I don’t know why you listen to everything my

wife says.CLINICIAN: How many days of work did you miss in the last two months?EXECUTIVE: A couple.CLINICIAN: Are you saying that you missed only two days of work?EXECUTIVE: Maybe a few.

F I C T I O N

✓

You cannot be psychologically dependent on adrug without also being physically dependent on it.

❑ FALSE. You can become psychologicallydependent on a drug without developing a physio-logical dependence.

T R U T H or

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depressant A drug that lowers the level ofactivity of the central nervous system.

CLINICIAN: Only three or four days?EXECUTIVE: Maybe a little more.CLINICIAN: Ten? Fifteen?EXECUTIVE: Fifteen.CLINICIAN: All because of cocaine?EXECUTIVE: No.CLINICIAN: How many were because of cocaine?EXECUTIVE: Less than fifteen.CLINICIAN: Fourteen? Thirteen?EXECUTIVE: Maybe thirteen.CLINICIAN: So you missed thirteen days of work in the last two months because of

cocaine. That’s almost two days a week.EXECUTIVE: That sounds like a lot but it’s no big deal. Like I say, the company can

run itself.CLINICIAN: How long have you been using cocaine?EXECUTIVE: About three years.CLINICIAN: Did you ever use drugs or alcohol before that in any kind of quantity?EXECUTIVE: No.CLINICIAN: Then let’s think back five years. Five years ago, if you had imagined

yourself missing over a third of your workdays because of a drug, and if you hadimagined yourself spending the equivalent of $84,000 a year on that same drug,and if you saw your once-successful business collapsing all around you, wouldn’tyou have thought that that was indicative of a pretty serious problem?

EXECUTIVE: Yes, I would have.CLINICIAN: So what’s different now?EXECUTIVE: I guess I just don’t want to think about it.

—From Weiss & Mirin, 1987, pp. 79–80

As routine drug use continues, problems mount. Users devote more resourcesto drugs. They ravage family bank accounts, seek “temporary” loans from friendsand family for trumped-up reasons, and sell family heirlooms and jewelry for afraction of their value. Lying and manipulation become a way of life to cover upthe drug use. The husband sells the TV set and forces the front door open to makeit look like a burglary. The wife claims to have been robbed at knifepoint to explainthe disappearance of a gold chain or engagement ring. Family relationships becomestrained as the mask of denial shatters and the consequences of drug abuse becomeapparent: days lost from work, unexplained absences from home, rapid moodshifts, depletion of family finances, failure to pay bills, stealing from family mem-bers, and missing family gatherings or children’s birthday parties.

3. Addiction or dependence. Routine use becomes addiction or dependence whenusers feel powerless to resist drugs, either because they want to experience theireffects or to avoid the consequences of withdrawal. Little or nothing else mattersat this stage, as we saw in the case of Eugene with which we opened the chapter.

Now let us examine the effects of different types of drugs of abuse and the conse-quences associated with their use and abuse.

DRUGS OF ABUSEDrugs of abuse are generally classified within three major groupings: (a) depressants,such as alcohol and opioids; (b) stimulants, such as amphetamines and cocaine; and(c) hallucinogens.

DepressantsA depressant is a drug that slows down or curbs the activity of the central nervoussystem. It reduces feelings of tension and anxiety, slows movement, and impairs cog-nitive processes. In high doses, depressants can arrest vital functions and cause death.


alcoholism An alcohol dependence disorderor addiction that results in serious personal,social, occupational, or health problems.

More teenagers and young adults die from alcohol-related motor vehicle accidents than from anyother cause.

❑ TRUE. Alcohol-related motor vehicle accidentsare the leading cause of death among teenagersand young adults.

✓


The most widely used depressant, alcohol, can cause death when taken in largeamounts because of its depressant effects on breathing. Other effects are specific to theparticular kind of depressant. For example, some depressants, such as heroin, producea “rush” of pleasure. Here let us consider several major types of depressants.

Alcohol Alcohol is the most widely abused substance in the United States and world-wide You might not think of alcohol as a drug, perhaps because it is so common, or per-haps because it is ingested by drinking rather than by smoking or injection. But alco-holic beverages—such as wine, beer, and hard liquor—contain a depressant drug calledethyl alcohol (or ethanol). The concentration of the drug varies with the type of bever-age (wine and beer have less pure alcohol per ounce than distilled spirits such as rye,gin, or vodka). Alcohol is classified as a depressant because it has biochemical effectssimilar to those of a class of antianxiety agents or minor tranquilizers, the benzodi-azepines, which includes the well-known drugs diazepam (Valium) and chlordiazepoxide(Librium). We can think of alcohol as an over-the-counter tranquilizer.

Most American adults drink alcohol at least occasionally and do so in moderation.But many people develop significant problems with alcohol. Many lay and professionalpeople use the terms alcoholism and alcohol dependence interchangeably, as we will.We use either term to refer to a pattern of impaired control over the use of alcohol insomeone who has become physiologically dependent on the drug. An estimated eightmillion U.S. adults suffer from alcholism (Kranzler, 2006).

The most widely held view of alcoholism is the disease model, the belief that alco-holism is a medical illness or disease. From this perspective, once a person with alco-holism takes a drink, the biochemical effects of the drug on the brain create an irresistiblephysical craving for more. The disease model holds that alcoholism is a chronic, perma-nent condition. The peer-support group Alcoholics Anonymous (AA) subscribes to thisview, which is expressed in their slogan, “Once an alcoholic, always an alcoholic.” AAviews people suffering from alcoholism as either drinking or “recovering,” never “cured.”However, later in this chapter we shall see that some professionals, including the psy-chologists Linda and Mark Sobell, adopt a different perspective. Their research showsthat some alcohol abusers can learn skills of controlled social drinking that enables themto drink moderately without “falling off the wagon.” The contention that some peoplewith alcohol problems can learn to drink moderately remains controversial.

The personal and social costs of alcoholism exceed those of all illicit drugs com-bined. Alcohol abuse is connected with lower productivity, loss of jobs, and downwardmovement in socioeconomic status. Alcohol plays a role in many violent crimes,including assaults and homicides, and more than 180,000 rapes and sexual attacksannually in the United States (Bartholow & Heinz, 2006; Buddie & Testa, 2005;O’Farrell, Fals-Stewart, & Murphy, 2005). About 1 in 3 suicides in this country andabout the same proportion of deaths due to unintentional injury (such as from motorvehicle accidents) are linked to alcohol use (Dougherty et al., 2004; Sher, 2005;Shneidman, 2005). More teenagers and young adults die from alcohol-related motorvehicle accidents than from any other cause. Despite increased awareness about therisks of drinking and driving, fatal alcohol-related motor vehicle accidents are on therise (O’Donnell, 2003). All told, an estimated 100,000 people in the United States diefrom alcohol-related causes each year, mostly from motor vehicle crashes and alcohol-related diseases (Society for Neuroscience, 2005b).

Despite the popular image of the person who develops alcoholism as a skid-rowdrunk, only a small minority of people with alcoholism fit the stereotype. The greatmajority of people with alcoholism are quite ordinary—your neighbors, coworkers,friends, and members of your own family. They are found in all walks of life and everysocial and economic class. Many have families, hold good jobs, and live fairly comfort-ably. Yet alcoholism can have just as devastating an effect on the well-to-do as on theindigent, leading to wrecked careers and marriages, to motor vehicle and other acci-dents, and to severe, life-threatening physical disorders, as well as exacting an enor-mous emotional toll. Alcoholism is also linked to higher levels of domestic violenceand greater risk of divorce (Marshal, 2003).

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No single drinking pattern is exclusively associated with alco-holism. Some people with alcoholism drink heavily every day;others binge only on weekends. Others can abstain for lengthyperiods of time, but periodically “go off the wagon” and engagein episodes of binge drinking that last for weeks or months.

Alcohol, not cocaine or other drugs, is the drug of choiceamong young people today and the leading drug of abuse.Drinking has become so integrated into college life that it isessentially normative, as much a part of the college experience asattending a weekend football or basketball game. Alcohol, notcocaine, heroin, or marijuana, is the BDOC—big drug oncampus (Johnston et al., 2004). Yet drinking often begins beforeyoung people reach college age. About 1 in 5 eighth-gradersreport having had a drink within the past month, along withmore than 1 in 3 tenth graders and about half of twelfth graders(The Center on Alcohol Marketing and Youth, 2005).

Drinking among college students tends to be limited to week-ends and to be heavier early in the semester when academicrequirements are relatively light (Del Boca et al., 2004). As a group,young adults in the 18- to 24-year age range show the highest ratesof alcohol use and the highest proportions of problem drinking(Ham & Hope, 2003). College students drink more than theirpeers who do not attend college (Slutske, 2005). Researchersdescribe a continuum of alcohol-related problems among collegestudents, ranging from mild problems, such as missing class, toextreme problem behaviors, such as arrests resulting from drink-ing (Ham & Hope, 2003). In the A Closer Look section, we focus ona particular form of problem drinking that has become a leadingproblem on college campuses today—binge drinking.

Risk Factors for Alcoholism A number of factors place peopleat increased risk for developing alcoholism and alcohol-relatedproblems. These include the following:

1. Gender. Men are more than twice as likely as women to develop alcoholism(Hasin et al., 2007). One possible reason for this gender difference is sociocultural;perhaps tighter cultural constraints are placed on women. Yet it may also be thatalcohol hits women harder, and not only because women usually weigh less thanmen. Alcohol seems to “go to women’s heads” more rapidly than men’s. This isapparently because women have less of an enzyme that metabolizes alcohol in thestomach than men do (Lieber, 1990). Ounce for ounce, women absorb more alco-hol into their bloodstreams than do men. As a result, they are likely to become ine-briated on less alcohol than men. Consequently, women’s bodies may put thebrakes on excessive drinking more quickly than men’s.

2. Age. The great majority of cases of alcohol dependence develop in young adult-hood, typically between the ages of 20 and 40. Although alcohol use disorders tendto develop somewhat later in women than in men, women who develop theseproblems experience similar health, social, and occupational problems by middleage as their male counterparts.

3. Antisocial personality disorder. Antisocial behavior in adolescence or adulthoodincreases the risk of later alcoholism. On the other hand, many people with alco-holism showed no antisocial tendencies in adolescence, and many antisocial ado-lescents do not abuse alcohol or other drugs as adults.

4. Family history. The best predictor of problem drinking in adulthood appears to bea family history of alcohol abuse. Family members who drink may act as models(“set a poor example”). Moreover, the biological relatives of people with alcoholdependence may also inherit a predisposition that makes them more likely todevelop problems with alcohol.

Q U E S T I O N N A I R EAre You Hooked?

Are you dependent on alcohol? If you shake and shiver andundergo the tortures of the darned (our editor insisted onchanging this word to maintain the decorum of a textbook)when you go without a drink for a while, the answer is clear

enough. However, sometimes the clues are more subtle.The following questions, adapted from the National Council on

Alcoholism’s self-test, can shed some light on the question. Simply place acheck mark in the “yes” or “no” column for each item. Then check the keyat the end of the chapter.

Source: Adapted from Newsweek, February 20, 1989, p. 52.

YES NO1. Do you sometimes go on drinking binges?2. Do you tend to keep away from your family

or friends when you are drinking?3. Do you become irritated when your family

or friends talk about your drinking?4. Do you feel guilty now and then about

your drinking?5. Do you often regret the things you have

said or done when you have been drinking?6. Do you find that you fail to keep the

promises you make about controllingor cutting down on your drinking?

7. Do you eat irregularly or not at all whenyou are drinking?

8. Do you feel low after drinking?9. Do you sometimes miss work or

appointments because of drinking?10. Do you drink more and more to get drunk?


Women and alcohol. Women are less likely to develop alcoholism, in part becauseof greater cultural constraints on excessive drinking by women, and perhaps becausewomen absorb more pure alcohol into the bloodstream than men, making them morebiologically sensitive to the effects of alcohol at the same level of intake as men.

5. Sociodemographic factors. Alcohol dependence is generally more common amongpeople of lower income and educational levels, as well as among people livingalone (Anthony et al., 1994).

Ethnicity and Alcohol Use and Abuse Rates of alcohol use and alcoholism varyamong American ethnic and racial groups. Some groups—Jews, Italians, Greeks, andAsian—have relatively low rates of alcoholism, largely as the result of tight social con-trols placed on excessive and underage drinking. Asian Americans, in general, drink lessheavily than other population groups (Adelson, 2006; Wong, Klingle, & Price, 2004).Not only do Asian families place strong cultural constraints on excessive drinking, butan underlying biological factor may be at work in curbing alcohol use. Asian Americansare more likely than other groups to show a flushing response to alcohol. Flushing ischaracterized by redness and feelings of warmth on the face, and, at higher doses, nau-sea, heart palpitations, dizziness, and headaches. Genes that control the metabolism ofalcohol are believed to be responsible for the flushing response (Luczak, Glatt, & Wall,2006). Because people like to avoid these unpleasant experiences, flushing may serve asa natural defense against alcoholism by curbing excessive alcohol intake.

Hispanic American men and non-Hispanic White men have similar rates of alcoholconsumption and alcohol-related physical problems. Hispanic American women,however, are much less likely to use alcohol and to develop alcohol use disorders thannon-Hispanic White women. Why? An important factor may be cultural expectations.Traditional Hispanic American cultures place severe restrictions on the use of alcoholby women, especially heavy drinking. However, with increasing acculturation,Hispanic American women in the United States apparently are becoming more similarto Euro American women with respect to alcohol use and abuse.

Alcohol abuse is taking a heavy toll on African Americans. For example, the preva-lence of cirrhosis, a degenerative, potentially fatal liver disease, is nearly twice as highin African Americans as in non-Hispanic White Americans. Yet African Americans aremuch less likely than non-Hispanic White Americans to develop alcohol abuse ordependence (Grant et al., 1994). Why, then, do African Americans suffer more fromalcohol-related problems?

Socioeconomic factors may help explain these differences. African Americansare more likely to encounter the stresses of unemployment and economic hard-

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ship, and stress may compound the damage to the body caused by heavy alcoholconsumption. African Americans also tend to lack access to medical services andmay be less likely to receive early treatment for the medical problems caused byalcohol abuse.

Although rates of alcohol abuse and dependence vary from tribe to tribe, NativeAmerican overall have high rates of alcoholism and suffer more from alcohol-relatedproblems than any other ethnic group—problems such as cirrhosis of the liver, fetalabnormalities, and automobile and other accident-related fatalities (Hasin et al., 2007;Hawkins et al., 2004; Mitchell et al., 2006).

Many Native Americans believe the loss of their traditional culture is largelyresponsible for their high rates of drinking-related problems (Beauvais, 1998). Thedisruption of traditional Native American culture caused by the appropriation ofIndian lands and by attempts by European American society to sever NativeAmericans from their cultural traditions while denying them full access to thedominant culture resulted in severe cultural and social disorganization (Kahn,1982). Beset by such problems, Native American adults are also prone to childabuse and neglect. Abuse and neglect contribute to feelings of hopelessness anddepression among adolescents, who may seek escape from their feelings by usingalcohol and other drugs.

Psychological Effects of Alcohol The effects of alcohol or other drugs vary from per-son to person. By and large they reflect the interaction of (a) the physiological effectsof the substances, and (b) our interpretations of those effects. What do most peopleexpect from alcohol? People frequently hold stereotypical expectations that alcoholwill reduce tension, enhance pleasurable experiences, wash away worries, and enhancesocial skills. But what does alcohol actually do?

At a physiological level, alcohol appears to work like the benzodiazepines (afamily of antianxiety drugs), by heightening activity of the neurotransmitterGABA (see Chapter 6). Because GABA is an inhibitory neurotransmitter (it tonesdown nervous system activity), increasing GABA activity produces feelings of

A L C O H O L I S M :

The Case of Chris“Toughest thing I ever did was admittingI had a problem.”

Alcohol and ethnic diversity. The damaging effects of alcohol abuse appear to be taking theheaviest toll on African Americans and Native Americans. The prevalence of alcohol-related cir-rhosis of the liver is nearly twice as high among African Americans than among White Americans,even though African Americans are less likely to develop alcohol abuse or dependence disorders.Jewish Americans have relatively low incidences of alcohol-related problems, perhaps becausethey tend to expose children to the ritual use of wine in childhood and impose strong culturalrestraints on excessive drinking. Asian Americans tend to drink less heavily than most otherAmericans, in part because of cultural constraints and possibly because they have less biologicaltolerance of alcohol, as shown by a greater flushing response to alcohol.


relaxation. As people drink, their senses become clouded, and balance and coordi-nation suffer. Still higher doses act on the parts of the brain that regulate involun-tary vital functions, such as heart rate, respiration rate, and body temperature.

People may do many things when drinking that they would not do when sober,in part because of expectations concerning the drug, in part because of the drug’seffects on the brain. For example, they may become more flirtatious or sexuallyaggressive or say or do things they later regret. Their behavior may reflect theirexpectation that alcohol has liberating effects and provides an external excuse forquestionable behavior. Later, they can claim, “It was the alcohol, not me.” The drugmay also impair the brain’s ability to curb impulsive, risk-taking, or violent behav-ior, perhaps by interfering with information-processing functions. Investigatorsfind strong links between alcohol use and violent behavior (Boles & Miottoa,

A major problem receiving a great deal of attention on college campusestoday is binge drinking. About 4 in 10 college students today report engag-ing in binge drinking (Ham & Hope, 2003)—drinking 5 or more drinks (formen) or 4 or more drinks (for women) on a single occasion.

Concerns about binge drinking are well placed. Binge drinking is linked to increased risks of serious motor vehicle and other accidents, violent andaggressive behavior, poor grades, sexual promiscuity, and development of sub-stance abuse and dependence (Chassin et al., 2002; Naimi et al., 2003; Sink,2004). Consider the tragic case of Leslie, a young college student at theUniversity of Virginia. An art major whose work her professors found promis-ing, Leslie had maintained a 3.67 GPA and was completing her senior essayon a Polish-born sculptor (Winerip, 1998). But she never finished it, becauseone day after binge drinking, she fell down a flight of stairs and died. We mayhear more about the deaths of young people due to heroin or cocaine over-doses, but hundreds of college students, like Leslie, die from alcohol-relatedcauses such as overdoses and accidents each year (Li et al., 2001).

In a recent review article, Lindsay Ham and Debra Hope (2003) identifiedtwo general subtypes of college students who appear most clearly at risk ofbecoming problem drinkers. The first type includes students who drink mostlyfor social or enjoyment purposes. They tend to be male, Anglo-American, andparticipate in Greek organizations or other social organizations in which heavydrinking is socially acceptable. The second type includes students who drinkdue to pressures to conform or who use alcohol to soothe negative feelings.They more often tend to be female and to be troubled by problems withanxiety or depression. Generating these profiles may help counselors andhealth-care providers identify young people at increased risk of developingproblem drinking patterns.

Binge drinking and related drinking games (beer chugging) can placepeople at significant risk of death from alcohol overdose. Many students whoplay these games don’t stop until they become too drunk or too sick to con-tinue (Johnson, 2002). What should you do if you see a friend or acquain-tance become incapacitated or pass out from heavy drinking? Should you justlet the person sleep it off? Can you tell whether a person has had too muchto drink? Should you just mind your own business or turn to others for help?

You cannot tell simply by looking at a person whether the person has over-dosed on alcohol. But a person who becomes unconscious or unresponsive is inneed of immediate medical attention. Don’t assume that the person will simply“sleep it off”: He or she may never wake up. Be aware of the signs of potentialoverdose, such as the following (adapted from Nevid & Rathus, 2007).

• Nonresponsive when talked to or shouted at• Nonresponsive to being pinched, shaken, or poked

• Unable to stand up on his or her own• Failure to wake up or gain consciousness• Purplish color or clammy-feeling skin• Rapid pulse rate or irregular heart rhythms, low blood pressure,

or difficulty breathing.

If you suspect an overdose, do not leave the person alone. Summonmedical help or emergency assistance and remain with the person until helparrives. If possible place the person on the side or have the person sit upwith his or her head bowed. Do not give the person any food or drink orinduce vomiting. If the person is responsive, find out if he or she had takenany medication or other drugs that might be interacting with the effects ofthe alcohol. Also, find out whether the person has an underlying illness thatmay contribute to the problem, such as diabetes or epilepsy.

It may be easier to just pass by without taking action. But ask yourselfwhat you would like someone else to do if you showed signs of overdosingon alcohol. Wouldn’t you want one of your friends to intervene to saveyour life?

A CLOSER LOOK

Binge Drinking, a Dangerous College Pastime

A dangerous pastime. Beer chugging and binge drinkingcan quickly lead to an alcohol overdose, a medical emer-gency that can have lethal consequences. Many collegeofficials cite binge drinking as the major drug problem oncampus.

It is safe to let someone who has passed out fromdrinking just “sleep it off.”

❑ FALSE. Sadly, the person may never wake up.Passing out from drinking needs to be treated as amedical emergency.

✓


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2003), including domestic violence and sexual assaults (Abbey et al., 2004; Fals-Stewart, 2003; Marshal, 2003).

Although alcohol makes people feel more relaxed and self-confident, it also impairsjudgment, which can lead them to make choices they would ordinarily reject, such asengaging in risky sex. Chronic alcohol abuse can impair cognitive abilities, such asmemory, problem solving, and attention (Ratti et al., 2002).

One of the lures of alcohol is that it induces short-term feelings of euphoria and ela-tion that can drown self-doubts and self-criticism. Alcohol also makes people less capa-ble of perceiving the unfortunate consequences of their behavior.

Alcohol use can dampen sexual arousal or excitement and impair sexual per-formance. As an intoxicant, alcohol also hampers coordination and motor ability.These effects help explain why alcohol use is implicated in about one in three acci-dental deaths in the United States.

Physical Health and Alcohol Chronic, heavy alcohol use affects virtually every organand body system, either directly or indirectly. Heavy alcohol use is linked to increasedrisk of many serious health concerns, including liver disease, increased risk of someforms of cancer, coronary heart disease, and neurological disorders. Two of the majorforms of alcohol-related liver disease are alcoholic hepatitis, a serious and potentiallylife-threatening inflammation of the liver, and cirrhosis of the liver, a potentially fataldisease in which healthy liver cells are replaced with scar tissue.

Habitual drinkers tend to be malnourished, which can put them at risk of com-plications arising from nutritional deficiencies. Chronic drinking is thus associatedwith such nutritionally linked disorders as cirrhosis of the liver (linked to proteindeficiency) and alcohol-induced persisting amnestic disorder (connected with vita-min B deficiency). This condition, also known as Korsakoff ’s syndrome, is charac-terized by glaring confusion, disorientation, and memory loss for recent events (seeChapter 15).

Mothers who drink during pregnancy place their fetuses at risk for infant mortal-ity, birth defects, central nervous system dysfunctions, and later academic problems.Children whose mothers drink during pregnancy may develop fetal alcohol syndrome(FAS), a syndrome characterized by facial features such as a flattened nose, widelyspaced eyes, and underdeveloped upper jaw, as well as mental retardation and socialskills deficits (Carroll, 2003; O’Connor et al., 2006). FAS affects from 1 to 3 of every1,000 live births.

We don’t know whether a minimum amount of alcohol is needed to produce FAS.Although the risk is greater among women who drink heavily during pregnancy, FAShas been found among children of mothers who drank as little as a drink and a halfper week (Carroll, 2003). Although the question of whether there is any safe dose ofalcohol during pregnancy continues to be debated, the fact remains that FAS is anentirely preventable birth defect. The safest course for women who know or suspectthey are pregnant is not to drink. Period.

Moderate Drinking: Is There a Health Benefit? Despite this list of adverseeffects associated with heavy drinking, evidence shows that moderate use of alco-hol (1 to 2 drinks per day for women, 2 to 4 drinks for men) is linked to lower risksof heart attacks and strokes, as well as lower death rates overall (Di Castelnuovo etal., 2006; Mukamal et al., 2003; Reynolds et al., 2003). Higher doses of alcohol areassociated with higher mortality (death) rates. Researchers suspect that alcoholmay help prevent the formation of blood clots that can clog arteries and lead toheart attacks. Alcohol also appears to increase the levels of HDL cholesterol, theso-called good cholesterol that sweeps away fatty deposits along artery walls(Goldberg et al., 2001). Although moderate use of alcohol may have a protectiveeffect on the heart and circulatory system, public health officials have not endorsedusing alcohol for this reason, based largely on concerns that such an endorsementmay increase the risks of problem drinking. Health promotion efforts might be


Even moderate use of alcohol increases the risk ofheart attacks.

❑ FALSE. Findings from recent studies show thatmoderate intake of alcohol is associated with alower risk of heart attacks and lower death rates.

✓


barbiturates Sedative drugs which aredepressants with high addictive potential.

better directed toward finding safer ways of achieving the health benefits associat-ed with moderate drinking than by encouraging alcohol consumption, such as byquitting smoking, lowering dietary intake of fat and cholesterol, and exercisingmore regularly.

Barbiturates About 1% of adult Americans develop a substance abuse or dependencedisorder involving the use of barbiturates, sleep medication (hypnotics), or antianxietyagents at some point in their lives. Barbiturates such as amobarbital, pentobarbital, pheno-barbital, and secobarbital are depressants, or sedatives. These drugs have several medicaluses, including easing anxiety and tension, dulling pain, and treating epilepsy and highblood pressure. Barbiturate use quickly leads to psychological dependence and physiologi-cal dependence in the form of both tolerance and development of a withdrawal syndrome.

Barbiturates are also popular street drugs because they are relaxing and produce amild state of euphoria, or “high.” High doses of barbiturates, like alcohol, producedrowsiness, slurred speech, motor impairment, irritability, and poor judgment—a par-ticularly deadly combination of effects when their use is combined with operation ofa motor vehicle. The effects of barbiturates last from 3 to 6 hours.

Because of synergistic effects, a mixture of barbiturates and alcohol is about 4 timesas powerful as either drug used by itself. A combination of barbiturates and alcohol isimplicated in the deaths of the entertainers Marilyn Monroe and Judy Garland. Evensuch widely used antianxiety drugs as Valium and Librium, which have a wide marginof safety when used alone, can be dangerous and lead to overdoses when combinedwith alcohol (APA, 2000).

Physiologically dependent people need to be withdrawn carefully, and only undermedical supervision, from sedatives, barbiturates, and antianxiety agents. Abrupt with-drawal can produce states of delirium that may involve visual, tactile, or auditory hal-lucinations and disturbances in thinking processes and consciousness. The longer theperiod of use and the higher the doses used, the greater the risk of severe withdrawaleffects. Epileptic (grand mal) seizures and even death may occur if the individualundergoes untreated, abrupt withdrawal.

Opioids Opioids are classified as narcotics—addictive drugs that have pain-relievingand sleep-inducing properties. Opioids include both naturally occurring opiates(morphine, heroin, codeine) derived from the juice of the poppy plant and syntheticdrugs (e.g., Demerol, Darvon) that have opiatelike effects. The ancient Sumeriansnamed the poppy plant opium, meaning “plant of joy.”

Opioids produce a rush, or intense feelings of pleasure, which is the primary reasonfor their popularity as street drugs. They also dull awareness of one’s personal prob-lems, which is attractive to people seeking a mental escape from stress. Their pleasur-able effects derive from their ability to directly stimulate the brain’s pleasure circuits—the same brain networks responsible for feelings of sexual pleasure or pleasure fromeating a satisfying meal (Begley, 2001b).

The major medical application of opioids—natural or synthetic—is the relief ofpain, or analgesia. Medical use of opioids, however, is carefully regulated because over-doses can lead to coma and even death. Street use of opioids is associated with manyfatal overdoses and accidents. In a number of American cities, young men are morelikely to die of a heroin overdose than in an automobile accident (Alter, 2001).

About 3 million Americans have used heroin and nearly 1 million are believed to beaddicted to the drug (Krantz & Mehler, 2004). Once dependence sets in, it usuallybecomes chronic, relieved by brief periods of abstinence (APA, 2000).

Adding to the problem is that prescription opioids too, used medically for painrelief, can become drugs of abuse when they are used illicitly as street drugs (Friedman,2006). Recent estimates indicate that about 7% of college students have used the pre-scription opioid Vicodin without a prescription (Whitten, 2006). Among twelfthgraders, about 5.5% report using another opioid, OxyContin, and 9.5% report taking

narcotics Drugs that are used medically forpain relief but that have strong addictivepotential.

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endorphins Natural substances that functionas neurotransmitters in the brain and aresimilar in their effects to morphine.

morphine A strongly addictive narcoticderived from the opium poppy that relievespain and induces feelings of well-being.

heroin A narcotic derived from morphinethat has strong addictive properties.

Vicodin (MTF Survey, 2006). Eric, an 18-year-old living in San Francisco, explains howhe is able to get Vicodin so easily, although he underestimates its risks:

“I can get prescription drugs from different places and don’t ever have to see a doctor. . . .I have friends whose parents are pill addicts, and we ‘borrow’ from them. Other times I havefriends who have ailments who get lots of pills and sell them for cheap. As long as prescriptionpills are taken right, they’re much safer than street drugs.”

—Cited in Friedman, 2006, p. 1148

Two discoveries made in the 1970s show that the brain produces chemicals of itsown that have opiatelike effects. One was that neurons in the brain have receptor sitesthat opiates fit like a key in a lock. The second was that the human body produces itsown opiatelike substances that dock at the same receptor sites as opiates do. These nat-ural substances, or endorphins, play important roles in regulating natural states ofpleasure and pain. Opioids mimic the actions of endorphins by docking at receptorsites intended for them, which in turn stimulates the brain centers that produce pleas-urable sensations.

The withdrawal syndrome associated with opioids can be severe. It begins within 4to 6 hours of the last dose. Flulike symptoms are accompanied by anxiety, feelings ofrestlessness, irritability, and cravings for the drug. Within a few days, symptomsprogress to rapid pulse, high blood pressure, cramps, tremors, hot and cold flashes,fever, vomiting, insomnia, and diarrhea, among others. Although these symptoms canbe uncomfortable, they are usually not devastating, especially when other drugs areprescribed to relieve them. Moreover, unlike withdrawal from barbiturates, the with-drawal syndrome rarely results in death.

Morphine Morphine—which receives its name from Morpheus, the Greek god ofdreams—was introduced at about the time of the U.S. Civil War. Morphine, a powerfulopium derivative, was used liberally to deaden pain from wounds. Physiologicaldependence on morphine became known as the “soldier’s disease.” There was little stig-ma attached to dependence until morphine became a restricted substance.

Heroin Heroin, the most widely used opiate, is a powerfuldepressant that can create a euphoric rush. Users of heroin claimthat it is so pleasurable it can eradicate any thought of food orsex. Heroin was developed in 1875 during a search for a drugthat would relieve pain as effectively as morphine, but withoutcausing addiction. Chemist Heinrich Dreser transformed mor-phine into a drug believed to have “heroic” effects in relievingpain without addiction, which is why it was called heroin.Unfortunately, heroin does lead to physiological dependence.

Estimates are that some 3 million Americans have usedheroin, which is the most widely used and abused opioid, andnearly 1 million are addicted (Krantz & Mehler, 2004). Heroinis usually injected either directly beneath the skin (skin popping)or into a vein (mainlining). The positive effects are immediate.There is a powerful rush that lasts from 5 to 15 minutes and astate of satisfaction, euphoria, and well-being that lasts from 3to 5 hours. In this state, all positive drives seem satisfied. Allnegative feelings of guilt, tension, and anxiety disappear. Withprolonged usage, addiction can develop. Many physiologicallydependent people support their habits through dealing (sellingheroin), prostitution, or selling stolen goods. Heroin is adepressant, however, and its chemical effects do not directlystimulate criminal or aggressive behavior.

Shooting up. Heroin users often inject the substance directly into theirveins. Heroin is a powerful depressant that provides a euphoric rush. Usersoften claim that heroin is so pleasurable that it obliterates any thought offood or sex.


stimulants Psychoactive substances thatincrease the activity of the nervous system.

StimulantsStimulants are psychoactive substances that increase the activity of the central nerv-ous system, which enhances states of alertness and can produce feelings of pleasure oreven euphoric highs. The effects vary with the particular drug.

Amphetamines The amphetamines are a class of synthetic stimulants. Street namesfor stimulants include speed, uppers, bennies (for amphetamine sulfate; trade nameBenzedrine), “meth” (for methamphetamine; trade name Methedrine), and dexies (fordextroamphetamine; trade name Dexedrine).

Amphetamines are used in high doses for their euphoric rush. They are oftentaken in pill form or smoked in a relatively pure form called “ice” or “crystal meth.”The most potent form of amphetamine, liquid methamphetamine, is injecteddirectly into the veins and produces an intense and immediate rush. Some usersinject methamphetamine for days on end to maintain an extended high. Eventuallysuch highs come to an end. People who have been on extended highs sometimes“crash” and fall into a deep sleep or depression. Some people commit suicide on theway down. High doses can cause restlessness, irritability, hallucinations, paranoiddelusions, loss of appetite, and insomnia.

Almost 3 times as many people have used “meth” as have used heroin (Bonné,2001). About 5% of Americans age 12 or older report using “meth” and about 0.2% (2in a thousand) report current (past-month) use (SAMHSA, 2006). This amounts tomore than 12 million Americans who have used “meth” at some point in their lives(Jefferson, 2005). Physiological dependence can develop from using amphetamines,leading to an abstinence syndrome characterized by depression and fatigue, as well asby unpleasant, vivid dreams, insomnia or hypersomnia (excessive sleeping), increasedappetite, and either a slowing down of motor behavior or agitation (APA, 2000).Psychological dependence is seen most often in people who use amphetamines as away of coping with stress or depression.

Methamphetamine abuse can cause brain damage, producing deficits in learningand memory in addition to other effects (Thompson et al., 2004; Toomey et al., 2003;Volkow et al., 2001). Violent behavior may also occur, especially when the drug issmoked or injected intravenously. The hallucinations and delusions of amphetaminepsychosis mimic those of paranoid schizophrenia, which has encouraged researchersto study the chemical changes induced by amphetamines as possible clues to theunderlying causes of schizophrenia.

Ecstasy The drug ecstasy, or MDMA (3,4-methylenedioxymethamphetamine)is a designer drug, a chemical knockoff similar in chemical structure to amphet-amine. It produces mild euphoria and hallucinations and has become especial-ly popular on college campuses and in clubs and “raves” in many cities(Hernandez, 2000; Strote & Wechsler, 2002). On the other hand, teen use ofecstasy dropped significantly in the early years of the new millennium (“FewerTeens,” 2004). Perhaps the message about the dangers of ecstasy are beginningto get across to young people.

Ecstasy can produce adverse psychological effects, including depression,anxiety, insomnia, and even paranoia and psychosis. The drug may alsoimpair cognitive functioning, including learning ability and attention, andmay have long-lasting effects on memory (Reneman, et al., 2001). Scientistssuspect that the drug may kill dopamine-using neurons in the brain, whichcan have long-lasting effects on the ability to experience pleasure in every-day life experiences (Ricaurte et al., 2002). Physical side effects include higher heartrate and blood pressure, a tense or chattering jaw, and body warmth and/or chills(Braun, 2001). The drug can be lethal when taken in high doses. Despite its risks,many users—including most teens—believe (mistakenly) that it is relatively safe(“Teens See Little Risk,” 2003).

Cocaine It might surprise you to learn that the original formula for Coca-Colacontained an extract of cocaine. In 1906, however, the company withdrew cocaine

amphetamine psychosis A psychoticstate induced by ingestion of amphetamines.

Ecstasy. Recreational use of the drug ecstasyhas become popular in many clubs cateringto young people. Yet even occasional use ofthe drug may affect cognitive functioning,such as learning, memory, and attention.High doses can be lethal.

cocaine A stimulant derived from the leavesof the coca plant.

amphetamines A class of stimulants thatactivate the central nervous system,producing heightened states of arousal andfeelings of pleasure.

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Coca-Cola originally contained cocaine.

❑ TRUE. The original formula for Coca-Cola contained an extract of cocaine.

crack The hardened, smokable form ofcocaine.

from its secret formula. The drink was originally described as a “brain tonic and intel-lectual beverage,” in part because of its cocaine content. Cocaine is a natural stimulantextracted from the leaves of the coca plant—the plant from which the soft drinkobtained its name. Coca-Cola is still flavored with an extract from the coca plant, onethat is not known to be psychoactive.

It was long believed that cocaine was not physically addicting. However, the drugproduces a tolerance effect and an identifiable withdrawal syndrome, which is charac-terized by depressed mood and disturbances in sleep and appetite (APA, 2000). Intensecravings for the drug and loss of ability to experience pleasure may also be present.Withdrawal symptoms are usually brief in duration and may involve a “crash,” orperiod of intense depression and exhaustion, following abrupt withdrawal.

Cocaine is usually snorted in powder form or smoked in the form of crack, a hard-ened form of cocaine that may be more than 75% pure. Crack “rocks”—so calledbecause they look like small white pebbles—are available in small ready-to-smokeamounts and considered to be the most habit-forming street drug available. Crack pro-duces a prompt and potent rush that wears off in a few minutes. The rush from snort-ing powdered cocaine is milder and takes a while to develop, but it tends to lingerlonger than the rush of crack.

Freebasing also intensifies the effects of cocaine. In freebasing, cocaine in powderform is heated with ether, freeing the psychoactive chemical base of the drug, and thensmoked. Ether, however, is highly flammable.

Next to marijuana, cocaine is the most widely used illicit drug in the United States.Nearly 14% of Americans age 12 and older have used cocaine and about 0.8% arecurrent (past-month) users (SAMHSA, 2006).

Effects of Cocaine Like heroin, cocaine directly stimulates the brain’s reward or pleas-ure circuits. It also produces a sudden rise in blood pressure and an accelerated heartrate that can cause potentially dangerous, even fatal, irregular heart rhythms.Overdoses can produce restlessness, insomnia, headaches, nausea, convulsions,tremors, hallucinations, delusions, and even sudden death due to respiratory or car-diovascular collapse. Regular snorting of cocaine can lead to serious nasal problems,including ulcers in the nostrils.

Repeated use and high-dose use of cocaine can lead to depression and anxiety.Depression may be severe enough to prompt suicidal behavior. Both initial and rou-tine users report episodes of “crashing” (feelings of depression after a binge), althoughcrashing is more common among long-term high-dose users. Psychotic behaviors,which can be induced by cocaine use as well as by use of amphetamines, tend tobecome more severe with continued use. Cocaine psychosis is usually preceded by aperiod of heightened suspiciousness, depressed mood, compulsive behavior, faultfind-ing, irritability, and increasing paranoia. The psychosis may also include intense visualand auditory hallucinations and delusions of persecution.

Nicotine Habitual smoking is not merely a bad habit: It is also a physical addiction toa stimulant drug, nicotine, found in tobacco products including cigarettes, cigars, andsmokeless tobacco (American Cancer Society, 2004). Smoking is also deadly, claimingmore than 400,000 lives in the United States alone, most from lung cancer and otherlung diseases, as well as cardiovascular (heart and artery) disease (Teo et al., 2006;Zickler, 2004). Smoking doubles the risk of dying in midlife (prior to age 70) (Doll et al.,2004; Vollset, Tverdal, & Gjessing, 2006). Figure 9.2 shows the percentages of deathsdue to smoking associated with several of the leading causes of death.

The World Health Organization estimates that 1 billion people worldwide smokeand more than 3 million die each year from smoking-related causes. The good news isthat the percentage of Americans who smoke declined from 42% in 1966 to about 21%today (CDC, 2005; TIPS, 2005). The bad news is that 21% of Americans still smokeand that rates of teenage smoking are on the rise, portending increased rates of adultsmoking and premature deaths in the years ahead.

✓



Per

cent

age

of D

eath

s100

80

60

40

20

0Lung

CancerChronic Lung

DiseaseCoronary

Heart Disease

Stroke

It may surprise you to learn that more women die of lung cancer than any othertype of cancer, including breast cancer (Springen, 2004). Although quitting smokingclearly has health benefits for women and men, it unfortunately does not reduce therisks to normal (nonsmoking) levels. The lesson is clear: If you don’t smoke, don’tstart; if you do smoke, quit.

Ethnic differences in smoking rates are shown in Figure 9.3. With the exception ofNative Americans (American Indian/Alaskan Native), women in each ethnic group areless likely to smoke than their male counterparts. Smoking is also becoming increas-ingly concentrated among people at lower income and educational levels.

Breast cancer is the leading cause of cancer deathsamong U.S. women.

❑ FALSE. Lung cancer has surpassed breastcancer as the leading cancer killer among women.It is also the leading cancer killer among men.Cigarette smoking is the culprit in the great majority of cases.

✓


Per

cent

age

of S

mok

ers

0

10

20

30

40

50

Male Female

White:Black:

Hispanic American:American Indian/Alaska Native:

Asian/Pacific Islander:

FIGURE 9.3 Ethnic and gender differences in rates of cigarette smoking among U.S.adults.Smoking rates are higher among Native Americans (American Indian and Alaska Native) thanother major racial/ethnic groups in the United States. Women in each ethnic group (with theexception of Native Americans) are less likely to smoke than their male counterparts.

Source: Cigarette Smoking Among Adults—United States, 2004. Morbidity and mortality weeklyreport, 54 (November 11, 2005).

FIGURE 9.2 Smoking-related causes ofdeath, by type of disease.Cigarette smoking accounts for nearly 90% ofdeaths due to lung cancer, about 80% ofdeaths due to chronic lung diseases, espe-cially emphysema, and about 20% of deathsdue to coronary heart disease and stroke.

Sources: U.S. Department of Health and HumanServices. Reducing the Health Consequencesof Smoking: 25 Years of Progress. A Report ofthe Surgeon General. Public Health Service,Centers for Disease Control, DHHS PublicationNo. (CDC) 89-8411, 1989; and Smoking.American Lung Association of Texas. http://www.texaslung.org, updated May 2004.

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hallucinogens Substances that cause hallucinations.

Nicotine is delivered to the body through the use of tobacco products. As a stimu-lant it increases alertness but can also give rise to cold, clammy skin, nausea and vomit-ing, dizziness and faintness, and diarrhea—all of which account for the discomforts ofnovice smokers. Nicotine also stimulates the release of epinephrine, a hormone thatgenerates a rush of autonomic nervous system activity, including rapid heartbeat andrelease of stores of sugar into the blood. Nicotine quells the appetite and provides apsychological “kick.” Nicotine also leads to the release of endorphins, the opiatelikehormones produced in the brain. This may account for the pleasurable feelings asso-ciated with tobacco use.

Habitual use of nicotine leads to physiological dependence on the drug. Nicotinedependence is associated with both tolerance (intake rises to a level of a pack or twoa day before leveling off) and a characteristic withdrawal syndrome. The withdrawalsyndrome for nicotine includes such features as lack of energy, depressed mood, irri-tability, frustration, nervousness, impaired concentration, lightheadedness and dizzi-ness, drowsiness, headaches, fatigue, irregular bowels, insomnia, cramps, loweredheart rate, heart palpitations, increased appetite, weight gain, sweating, tremors, andcraving for cigarettes (APA, 2000). It is nicotine dependence, not cigarette smokingper se, that is classifiable as a mental disorder in the DSM system. The great majorityof regular smokers (80% to 90%) meet diagnostic criteria for nicotine dependence(APA, 2000).

HallucinogensHallucinogens, also known as psychedelics, are a class of drugs that produce sensorydistortions or hallucinations, including major alterations in color perception and hear-ing. Hallucinogens may also have additional effects, such as relaxation and euphoria or,in some cases, panic.

Hallucinogens include lysergic acid diethylamide (LSD), psilocybin, and mescaline.Psychoactive substances that are similar in effect to psychedelic drugs are marijuana(cannabis) and phencyclidine (PCP). Mescaline is derived from the peyote cactus andhas been used for centuries by Native Americans in the Southwest, Mexico, and CentralAmerica in religious ceremonies, as has psilocybin, which is derived from certainmushrooms. LSD, PCP, and marijuana are the most commonly used hallucinogens inthe United States.

Although tolerance to hallucinogens may develop, we lack evidence of a consistentor clinically significant withdrawal syndrome associated with their use (APA, 2000).However, cravings following withdrawal may occur.

LSD LSD is the acronym for lysergic acid diethylamide, a synthetic hallucinogenicdrug. In addition to the vivid parade of colors and visual distortions produced by LSD,users have claimed it “expands consciousness” and opens new worlds—as if they werelooking into some reality beyond the usual reality. Sometimes they believe they haveachieved great insights during the LSD “trip,” but when it wears off they usually can-not follow through or even summon up these discoveries.

The effects of LSD are unpredictable and depend on the amount taken as well as theuser’s expectations, personality, mood, and surroundings. The user’s prior experienceswith the drug may also play a role, as users who have learned to handle the effects ofthe drug through past experience may be better prepared than new users.

Some users have unpleasant experiences with the drug, or “bad trips.” Feelings ofintense fear or panic may occur. Users may fear losing control or sanity. Some experi-ence terrifying fears of death. Fatal accidents have sometimes occurred during LSDtrips. Flashbacks, typically involving a reexperiencing of some of the perceptual distor-tions of the “trip,” may occur days, weeks, or even years afterward. Flashbacks tend tooccur suddenly and often without warning. Perceptual distortions may involve geo-metric forms, flashes of color, intensified colors, afterimages, or appearances of halosaround objects, among others (APA, 2000). They may stem from chemical changes in


marijuana A hallucinogenic drug derivedfrom the leaves and stems of the plantCannabis sativa.

the brain caused by the prior use of the drug. Triggers for flashbacks include entry intodarkened environments, drug use, anxiety or fatigue states, or stress. Psychological fac-tors, such as underlying personality problems, may also explain why some users expe-rience flashbacks. In some cases, a flashback may involve an imagined reenactment ofthe LSD experience.

Phencyclidine (PCP) Phencyclidine, or PCP—which is referred to as “angel dust” onthe streets—was developed as an anesthetic in the 1950s but was discontinued as suchwhen its hallucinatory side effects were discovered. A smokable form of PCP becamepopular as a street drug in the 1970s. However, its popularity has since waned, largelybecause of its unpredictable effects.

The effects of PCP, like most drugs, are dose related. In addition to causing halluci-nations, PCP accelerates the heart rate and blood pressure and causes sweating, flush-ing, and numbness. PCP is classified as a deliriant—a drug capable of producing statesof delirium. It also has dissociating effects, causing users to feel as if there is some sortof invisible barrier between themselves and their environments. Dissociation can beexperienced as pleasant, engrossing, or frightening, depending on the user’s expecta-tions, mood, setting, and so on. Overdoses can give rise to drowsiness and a blank stare,convulsions, and, now and then, coma; paranoia and aggressive behavior; and tragicaccidents resulting from perceptual distortion or impaired judgment during states ofintoxication.

Marijuana Marijuana is derived from the Cannabis sativa plant. Marijuana is gener-ally classified as a hallucinogen because it can produce perceptual distortions or mildhallucinations, especially in high doses or when used by susceptible individuals. Thepsychoactive substance in marijuana is delta-9-tetrahydrocannabinol, or, thankfully,THC for short. THC is found in branches and leaves of the plant but is highly con-centrated in the resin of the female plant. Hashish, or “hash,” also derived from theresin, is more potent than marijuana but has similar effects.

Use of marijuana exploded throughout the so-called swinging 1960s and the 1970s,but the drug then lost some (but not all) of its cachet. Still, marijuana remains ourmost widely used illegal drug, and abuse of marijuana is the most common of all thesubstance abuse disorders involving illicit drugs (Compton et al., 2004). That said, theprevalence of use and abuse of marijuana doesn’t compare with that of alcohol.

About 40% of Americans 12 years of age and older report having used marijuana orhashish in their lives, and about 6% are current (past-month) users (SAMHSA, 2006).About 1.5% of the U.S. adult population suffers from a marijuana abuse or depend-ence disorder (Compton et al., 2004). Males are more likely than females to develop amarijuana abuse or dependence disorder, and rates of these disorders are greatestamong people age 18 to 30 (APA, 2000).

Low doses of the drug can produce relaxing feelings similar to drinking alcohol.Some users report that at low doses the drug makes them feel more comfortable insocial gatherings. Higher doses, however, often lead users to withdraw into themselves.Some users believe the drug increases their capacity for self-insight or creative think-ing, although the insights achieved under its influence may not seem so insightful oncethe drug’s effects have passed. People may turn to marijuana, as to other drugs, to helpthem cope with life problems or to help them function when they are under stress.Strongly intoxicated people perceive time as passing more slowly. A song of a few min-utes may seem to last an hour. There is increased awareness of bodily sensations, suchas heartbeat. Smokers also report that strong intoxication heightens sexual sensations.Visual hallucinations may occur.

Strong intoxication can cause smokers to become disoriented. If their moods areeuphoric, disorientation may be construed as harmony with the universe. Yet somesmokers find strong intoxication disturbing. An accelerated heart rate and sharpenedawareness of bodily sensations cause some smokers to fear their hearts will “run away”with them. Some smokers are frightened by disorientation and fear they will not “comeback.” High levels of intoxication now and then induce nausea and vomiting.

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Therapist Jean Obert“Being addicted to heroin is one of themost difficult things to kick.”

Cannabis dependence is associated more with patterns of compulsive use or psy-chological dependence than with physiological dependence. Although tolerance tomany of the drug’s effects may occur with chronic use, some users report reverse tol-erance, or sensitization. Although a clear-cut withdrawal syndrome has not been reli-ably demonstrated, recent evidence identified a definable withdrawal syndromeamong long-term, heavy users who stopped using the drug abruptly (Budney et al.,2004). We have also learned that long-term use can lead to problems with both learn-ing and memory (Messinis et al., 2006; Solowij et al., 2002).

Evidence also links marijuana use to later use of harder drugs such as heroin andcocaine (Kandel, 2002, 2003). Whether marijuana use is a causal factor leading to useof harder drugs remains unclear. We do know that marijuana impairs perception andmotor coordination and thus makes driving and the operation of other heavy machin-ery dangerous. Although marijuana use induces positive mood changes in many users,some people report anxiety and confusion; there are also occasional reports of para-noia or psychotic reactions (Johns, 2001). Marijuana elevates heart rate and bloodpressure and is linked to an increased risk of heart attacks in people with heart disease.And like cigarettes, smoking marijuana can cause respiratory diseases, includingchronic bronchitis (Zickler, 2006).

THEORETICAL PERSPECTIVESPeople begin using psychoactive substances for various reasons. Some adolescents startusing drugs because of peer pressure or because they believe drugs make them seemmore sophisticated or grown up. Some use drugs as a way of rebelling against their par-ents or society at large. Regardless of why people get started with drugs, they continueto use them because drugs produce pleasurable effects or because they find it difficultto stop. Most adolescents drink alcohol to “get high,” not to establish that they areadults. Many people smoke cigarettes for the pleasure they provide. Others smoke tohelp them relax when they are tense and, paradoxically, to give them a kick or a lift whenthey are tired. Many would like to quit but find it difficult to break their addiction.

People who are anxious about their jobs or social lives may be drawn to the calm-ing effects of alcohol, marijuana (in certain doses), tranquilizers, and sedatives. Peoplewith low self-confidence and self-esteem may be drawn to the ego-bolstering effects ofamphetamines and cocaine. Many poor young people attempt to escape the poverty,anguish, and tedium of inner-city life through using heroin and similar drugs. Morewell-to-do adolescents may rely on drugs to manage the transition from dependenceto independence and major life changes concerning jobs, college, and lifestyles.

In the next sections we consider several major theoretical perspectives on substanceabuse and dependence.

Biological PerspectivesWe are beginning to learn more about the biological underpinnings of drug use andaddiction. Much of the recent research has focused on neurotransmitters, especiallydopamine, and on the role of genetic factors.

Neurotransmitters Many psychoactive drugs, including nicotine, alcohol, heroin,marijuana, and especially cocaine and amphetamines, increase levels of the neuro-transmitter dopamine in the brain’s pleasure or reward circuits—the networks of neu-rons responsible for producing feelings of pleasure or states of euphoria (Nestler, 2005;Pierce & Kumaresan, 2006; Society for Neuroscience, 2005c; Volkow et al., 2005;Zangen et al., 2006). Over time, regular use of these drugs reduces the brain’s own pro-duction of dopamine. Consequently, the brain’s natural reward system—the “feelgood” circuitry that produces states of pleasure associated with the ordinarily reward-ing activities of life, such as consuming a satisfying meal and engaging in pleasantactivities—becomes blunted (Dubovsky, 2006). In effect, the addict’s brain comes todepend on having the drug available to produce feelings of pleasure or satisfaction(Denizet-Lewis, 2006). Without drugs, life may not seem to be worth living.


ReceptorSites

Cocaine

Neurotransmitters

TerminalButton

SynapticCleft

FIGURE 9.4 Cocaine’s effects in the brain.Neurotransmitters are released into thesynapse (synaptic cleft or gap) from terminalbuttons at the end of axons. Normally, excessmolecules of neurotransmitters are reabsorbedby the terminal buttons of the transmittingneuron in a process called reuptake. Cocaine,as represented here by the orange circles,blocks this process of reuptake, allowing moreneurotransmitter molecules to remain in thesynapse, which creates a euphoric high byoverstimulating receiving neurons in brainnetworks regulating feelings of pleasure.

Changes in the dopamine system may help explain the intense cravings and anxietythat accompany drug withdrawal and the difficulty people have maintaining absti-nence. Although investigators highlight the role of dopamine in helping us understandthe biochemical bases of substance abuse and dependence, they recognize that otherneurotransmitters, including serotonin and endorphins, also play a role (Addolorato etal., 2005; Buchert et al., 2004).

Figure 9.4 shows the effects of cocaine in the brain. Use of the drug increases theavailability of neurotransmitters norepinephrine and dopamine by interfering with theprocess by which excess molecules of these chemicals are reabsorbed by the transmit-ting neuron through a process called reuptake. High levels of these neurotransmitterstherefore remain active in the synaptic gaps between neurons within brain networksthat control feelings of pleasure, thereby magnifying and extending feelings the pleas-urable effects of the drug (see Figure 9.4).

Endorphins are a class of neurotransmitters that have pain-blocking properties sim-ilar to those of opioids such as heroin. Endorphins and opiates dock at the same recep-tor sites in the brain. Normally, the brain produces a certain level of endorphins thatmaintains a psychological steady state of comfort and potential to experience pleasure.However, when the body becomes habituated to a supply of opioids, it may stop pro-ducing endorphins. This makes the user dependent on opiates for comfort, relief frompain, and pleasure. When the habitual user stops using heroin or other opiates, feelingsof discomfort and little aches and pains may be magnified until the body resumes ade-quate production of endorphins. This discomfort may account, at least in part, for theunpleasant withdrawal symptoms that opiate addicts experience. However, this modelremains speculative, and more research is needed to document direct relationshipsbetween endorphin production and withdrawal symptoms.

Genetic Factors Evidence links genetic factors to various forms of substance use andabuse, including alcohol abuse and dependence, heroin dependence, and even cigarettesmoking (nicotine dependence) (Feng et al., 2004; Hampton, 2006; Liu et al., 2004; Xuet al., 2004). Investigators have begun the hunt for specific genes involved in alcoholand drug abuse and dependence (e.g., Audrain-McGovern et al., 2004; Drakenberg et al.,2006). We focus on alcohol dependence, because this has been the area of greatestresearch interest.

Alcoholism tends to run in families (APA, 2000). The closer the genetic relationship,the greater the risk. Familial patterns provide only suggestive evidence of genetic factors,because families share a common environment as well as common genes. More defin-itive evidence comes from twin and adoptee studies.

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People who can “hold their liquor” better than moststand a lower risk of becoming problem drinkers.

❑ FALSE. A high physical tolerance for liquormay lead a person to drink excessively, which mayset the stage for problem drinking.

✓


Monozygotic (MZ) twins have identical genes, whereas fraternal or dizygotic (DZ)twins share only half of their genes. If genetic factors are involved, we would expect MZtwins to have higher concordance (agreement) rates for alcoholism than DZ twins.Evidence of higher concordance rates for alcoholism is found among MZ twins thanDZ twins, although the results are more consistent for male samples than female sam-ples (Wood et al., 2001).

A limitation of twin studies is that MZ twins may share more environmental as wellas genetic similarity than DZ twins. That is, they may be treated more alike than DZtwins. However, evidence also shows that male adoptees whose biological parents suf-fered from alcoholism have an increased risk of developing alcoholism themselves,even if they are raised in nondrinking homes (Gordis, 1995). Among women, however,the rate of alcoholism in adopted-away daughters of parents with alcoholism is onlyslightly higher than that for adopted-away daughters of nonalcoholics, thus castingdoubt on a strong genetic linkage to alcoholism in women (Svikis, Velez, & Pickens,1994). All in all, genetic factors are believed to play a moderate role in male alcoholismand a modest role in female alcoholism (McGue, 1993).

If alcoholism or other forms of substance abuse and dependence are influenced bygenetic factors, what exactly is inherited? Some clues are emerging (Corbett et al., 2005;Edenberg et al., 2005; Radel et al., 2005). Alcoholism, nicotine dependence, and opioidaddiction are linked to genes that determine the structure of dopamine receptors in thebrain. As we’ve noted, dopamine is involved in regulating states of pleasure, so one possi-bility is that genetic factors enhance feelings of pleasure derived from alcohol. The geneticvulnerability to alcoholism most probably involves a combination of factors, such as reap-ing greater pleasure from alcohol and a capacity for greater biological tolerance for thedrug. People who can tolerate larger doses of alcohol without incurring upset stomachs,dizziness, and headaches may have difficulty knowing when to stop drinking. Thus peoplewho are better able to “hold their liquor” may thus be at greater risk of developing drink-ing problems. They may need to rely on other cues, such as counting their drinks, to limittheir drinking. Other people whose bodies more readily “put the brakes” on excess drink-ing may be less likely to develop problems in moderating their drinking.

Whatever the role of heredity in alcohol dependence and other forms of substancedependence, genes do not dictate behavior; they interact with environmental factors(Kendler, Jacobson et al., 2003). For example, being raised in an environment free ofparental alcoholism is associated with a lower risk of alcohol-related disorders inpeople at high genetic risk of these disorders (Jacob et al., 2003). In sum, addictionexperts believe that multiple genes acting together with social, cultural, and psycho-logical factors contribute to the the development of alcoholism and other forms ofsubstance dependence (e.g., Dick et al., 2001).

Learning PerspectivesLearning theorists propose that substance-related behaviors are largely learned andcan, in principle, be unlearned. They focus on the roles of operant and classical condi-tioning and observational learning. Substance abuse problems are not regarded assymptoms of disease but rather as problem habits. Although learning theorists do notdeny that genetic or biological factors may increase susceptiblity to substance abuseproblems, but they emphasize the role of learning in the development and mainte-nance of these problem behaviors (McCrady, 1993, 1994). They also recognize thatpeople who suffer from depression or anxiety may turn to alcohol as a way of reliev-ing these troubling emotional states, however briefly. Evidence shows that emotionalstress, such as anxiety or depression, often sets the stage for the development of sub-stance abuse (Dixit & Crum, 2000; McGue, Slutske, & Iaono, 1999).

Drug use may become habitual because of the pleasure (positive reinforcement) ortemporary relief (negative reinforcement) from negative emotions, such as anxiety anddepression, which drugs can produce. With drugs like cocaine, which appear capableof directly stimulating pleasure mechanisms in the brain, the positive reinforcement isdirect and powerful.


Operant Conditioning People may initially use a drug because of social influence, trialand error, or social observation. In the case of alcohol, they learn that the drug can pro-duce reinforcing effects, such as feelings of euphoria, and reductions in anxiety and ten-sion. Alcohol may also reduce behavioral inhibitions. Alcohol can thus be reinforcingwhen it is used to combat depression (by producing euphoric feelings, even if short lived),to combat tension (by functioning as a tranquilizer), or to help people sidestep moralconflicts (for example, by dulling awareness of moral prohibitions). Substance abuse mayalso provide social reinforcers, such as the approval of drug-abusing companions and, inthe cases of alcohol and stimulants, the (temporary) overcoming of social shyness.

Alcohol and Tension Reduction Learning theorists have long maintained that one ofthe primary reinforcers for using alcohol is relief from states of tension or unpleasantstates of arousal. According to the tension-reduction theory, the more often one drinksto reduce tension or anxiety, the stronger or more habitual the habit becomes. We canthink of some uses of alcohol and other drugs as forms of self-medication—as a meansof using the pill or the bottle to ease psychological pain, at least temporarily (Bolton et al.,2006; Tomlinson et al., 2006). We can see this pattern of negative reinforcement (relieffrom psychological pain) in the following case example.

“Taking Away the Hurt I Feel”“I use them (the pills and alcohol) to take away the hurt I feel inside.” Joceyln, a 36-year-oldmother of two, was physically abused by her husband, Phil. “I have no self-esteem. I just don’t feelI can do anything,” she told her therapist. Joceyln had escaped from an abusive family backgroundby getting married at age 17, hoping that marriage would offer her a better life. The first few yearswere free of abuse, but things changed when Phil lost his job and began to drink heavily. By then,Jocelyn had two young children and felt trapped. She blamed herself for her unhappy family life,for Phil’s drinking, for her son’s learning disability. “The only thing I can do is drink or do pills. At least then I don’t have to think about things for awhile.” Although drug use temporarily dulledher emotional pain, it came with a greater long-term cost in terms of the burden of addiction.

—From the Author’s Files

Although nicotine, alcohol, and other drugs may temporarily alleviate emotionaldistress, they cannot resolve underlying personal or emotional problems. Rather thanlearning to resolve these problems, people who turn to alcohol or other drugs as formsof self-medication often find themselves facing additional substance-related problems.

Self-medication? People who turn to other drugs or alcohol to quell disturbingemotions can compound their problems by developing a substance use disorder.

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A Case of Conditioned Drug Cravings

A 29-year-old man was hospitalized for the treatment of heroin addiction. After 4weeks of treatment, he returned to his former job, which required him to ride thesubway past the stop at which he had previously bought his drugs. Each day, whenthe subway doors opened at this location, [he] experienced enormous craving forheroin, accompanied by tearing, a runny nose, abdominal cramps, and gooseflesh.After the doors closed, his symptoms disappeared, and he went on to work.

—From Weiss & Mirin, 1987, p. 71

Negative Reinforcement and Withdrawal Once people become physiologicallydependent, negative reinforcement comes into play in maintaining the drug habit. Inother words, people may resume using drugs to gain relief from unpleasant withdrawalsymptoms. In operant conditioning terms, relief from unpleasant withdrawal symp-toms is a negative reinforcer for resuming drug use (Higgins, Heil, & Lussier, 2004).For example, the addicted smoker who quits cold turkey may shortly return to smok-ing to fend off the discomfort of withdrawal.

The Conditioning Model of Cravings Classical conditioning may help explain drugcravings. In this view, cravings reflect the body’s need to restore high blood levels of theaddictive substance and thus have a biological basis. But they also come to be associatedwith environmental cues associated with prior use of the substance (Kilts et al., 2004).These cues, such as the sight or aroma of an alcoholic beverage or the sight of a needleand syringe, become conditioned stimuli that elicit a conditioned response: strongcravings for the drug. For example, socializing with certain companions (“drinkingbuddies”) or even passing a liquor store may elicit conditioned cravings for alcohol. Insupport of this theory, alcoholic subjects show distinctive changes in brain activity inareas of the brain that regulate emotion, attention, and appetitive behavior whenshown pictures of alcoholic beverages (George et al., 2001). Social drinkers, by com-parison, do not show this pattern of brain activation.

Sensations of anxiety or depression that are paired with the use of alcohol ordrugs may also elicit cravings. The following case illustrates conditioned cravings toenvironmental cues.

Similarly, some people are primarily “stimulus smokers.” They reach for a cigarettein the presence of smoking-related stimuli, such as seeing someone smoke or smellingsmoke. Smoking becomes a strongly conditioned habit because it is paired repeatedlywith many situational cues—watching TV, finishing dinner, driving in the car, study-ing, drinking or socializing with friends, sex, and, for some, using the bathroom.

The conditioning model of craving receives support from research showing thatpeople with alcoholism tend to salivate more than others at the sight and smell of alco-hol (Monti et al., 1987). Pavlov’s classic experiment conditioned a salivation responsein dogs by repeatedly pairing the sound of a bell (a conditioned stimulus) with thepresentation of food powder (an unconditioned stimulus). Salivation among peoplewho develop alcoholism can also be viewed as a conditioned response to alcohol-related cues. People with drinking problems who show the greatest salivary response toalcohol cues may be at highest risk of relapse. They may also profit from conditioning-based treatments designed to extinguish responses to alcohol-related cues.

In one treatment occurring over a series of sessions, called cue exposure training, theperson is seated in front of alcohol-related cues, such as open alcoholic beverages, butprevented from imbibing (Dawe et al., 2002). The pairing of the cue (alcohol bottle)with nonreinforcement (by dint of preventing drinking) may lead to extinction of theconditioned craving. However, cravings can, and often do, return after treatment whenpeople go back to their usual environments (Collins & Brandon, 2002; Havermans &Jansen, 2003).


Observational Learning Modeling or observational learning plays an important role indetermining risk of substance abuse problems. Parents who model inappropriate or exces-sive drinking or use of illicit drugs may set the stage for maladaptive drug use in theirchildren (Kirisci, Vanyukov, & Tarter, 2005). Evidence shows that adolescents who have aparent who smokes face a substantially higher risk of smoking than do their peers infamilies where neither parent smokes (Peterson et al., 2006). Other investigators find thathaving friends who smoke influences adolescents to begin smoking (Bricker et al., 2006).

Cognitive PerspectivesEvidence supports the role of cognitive factors in substance abuse and dependence,especially the role of expectancies. Expectancies about the perceived benefits of usingalcohol or other drugs and smoking cigarettes clearly influence the decision to usethese substances (Cable & Sacker, 2006; Mitchell et al., 2006; Park, 2004). Outcomeexpectancies in teens—what they expect a drug’s effects will be—are strongly influ-enced by the beliefs of their peers. The degree to which friends hold positive attitudestoward alcohol use is thus an important factor in alcohol use in adolescents (Wood etal., 2001). Public health campaigns appear to be having some impact in changingattitudes of young people toward cigarette smoking. Adolescents in a Midwesterncommunity showed more negative attitudes toward smoking than did adolescents ageneration earlier (Chassin et al., 2003).

Alcohol or other drug use may also boost self-efficacy expectations—personalexpectancies we hold about our ability to successfully perform tasks. If we believe weneed a drink or two (or more) to “get out of our shell” and relate socially to others, wemay come to depend on alcohol in social situations.

Expectancies may account for the “one-drink effect”—the tendency of chronic alcoholabusers to binge once they have a drink. Psychologist G. Alan Marlatt (1978) explainedthe one-drink effect as a type of self-fulfilling prophecy. If people with alcohol-relatedproblems believe that just one drink will cause a loss of control, they may perceive theoutcome as predetermined when they drink. Having even one drink may thus escalateinto a binge. This type of expectation is an example of what Aaron Beck calls absolutistthinking. When we insist on seeing the world in black and white rather than shades ofgray—as either complete successes or complete failures—we may interpret one bite ofdessert as proof we are off our diets, or one cigarette as proof we are hooked again.Rather than telling ourselves, “Okay, I goofed, but that’s it. I don’t have to have more,”we encode our lapses as catastrophes and transform them into relapses. Still, alcohol-dependent people who believe they may go on a drinking binge if they have just onedrink are well advised to abstain.

Psychodynamic PerspectivesAccording to traditional psychodynamic theory, alcoholism reflects an oral-dependentpersonality. Psychodynamic theory also associates excessive alcohol use with other oraltraits, such as dependence and depression, and traces the origins of these traits to fix-ation in the oral stage of psychosexual development. Excessive drinking or smoking inadulthood symbolizes an individual’s efforts to attain oral gratification.

Research support for these psychodynamic concepts is mixed. Although people whodevelop alcoholism often show dependent traits, it is unclear whether dependence con-tributes to or stems from problem drinking. Chronic drinking, for example, is con-nected with loss of employment and downward movement in social status, both ofwhich would render drinkers more reliant on others for support. Moreover, an empir-ical connection between dependence and alcoholism does not establish that alco-holism represents an oral fixation that can be traced to early development.

Then too, many—but certainly not all—people who suffer from alcoholism haveantisocial personalities characterized by independence seeking as expressed throughrebelliousness and rejection of social and legal codes. All in all, there doesn’t appear tobe any single alcoholic personality (Wood et al., 2001).

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Sociocultural PerspectivesDrinking is determined, in part, by where we live, whom we worship with, and thesocial or cultural norms that regulate our behavior. Cultural attitudes can encourageor discourage problem drinking. As we have already seen, rates of alcohol abuse varyacross ethnic and religious groups. Let us note some other sociocultural factors.Church attendance, for example, is generally connected with abstinence from alcohol.Perhaps people who are more willing to engage in culturally sanctioned activities, suchas churchgoing, are also more likely to adopt culturally sanctioned prohibitions againstexcessive drinking. Rates of alcohol use also vary across cultures.

Peer pressure and exposure to a drug subculture are important influences in deter-mining substance use among adolescents and young adults (Dishion & Owen, 2002;Hu, Davies, &. Kandel, 2006). Kids who start drinking before age 15 stand a fivefoldhigher risk of developing alcohol dependence in adulthood than do teens who begandrinking at a later age (Kluger, 2001). Yet studies of Hispanic and African Americanadolescents show that support from family members can reduce the negative influenceof drug-using peers on the adolescent’s use of tobacco and other drugs (Farrell &White, 1998; Frauenglass et al., 1997).

TREATMENT OF SUBSTANCE ABUSE AND DEPENDENCEThere is a vast array of nonprofessional, biological, and psychological approaches tosubstance abuse and dependence. However, treatment has often been a frustratingendeavor. In many, perhaps most, cases, people with drug dependencies really do notwant to stop and do not seek treatment on their own. When people do come for treat-ment, helping them through the withdrawal syndrome is usually straightforwardenough, as we shall see. However, helping them pursue a life devoid of their preferredsubstances is more problematic. Treatment takes place in a setting—such as the thera-pist’s office, a support group, a residential center, or a hospital—in which abstinence isvalued and encouraged. Then the individual returns to the work, family, or street set-tings in which abuse and dependence were instigated and maintained. The problem ofrelapse can thus be more troublesome than the problems involved in initial treatment.

Peer pressure. Peer pressure is a major influence on alcohol and drug use among adolescents.


detoxification The process of ridding the system of alcohol or other drugs undersupervised conditions.

Another complication is that many people with substance abuse problems have otherpsychological disorders as well. However, most clinics and treatment programs focus onthe drug or alcohol problem, or the other psychological disorders, rather than treating allthese problems simultaneously. This narrow focus results in poorer treatment outcomes,including more frequent rehospitalizations among those with these dual diagnoses.

Biological ApproachesAn increasing range of biological approaches is used in treating problems of substanceabuse and dependence. For people with chemical dependencies, biological treatmenttypically begins with detoxification—that is, helping them through withdrawal fromaddictive substances.

Detoxification Detoxification is often more safely carried out in a hospital setting. In thecase of addiction to alcohol or barbiturates, hospitalization allows medical personnel tomonitor and treat potentially dangerous withdrawal symptoms such as convulsions.Antianxiety drugs, such as the benzodiazepines Librium and Valium, may help block severewithdrawal symptoms such as seizures and delirium tremens. Detoxification to alcoholtakes about a week. Detoxification is an important step toward staying clean, but it is onlya start. Approximately half of all drug abusers relapse within a year of detoxification(Cowley, 2001b). Continuing support and structured therapy, such as behavioral counsel-ing, plus possible use of therapeutic drugs, increase the chances of long-term success.

A number of therapeutic drugs are used in treating people with chemical depend-encies, and more chemical compounds are in the testing stage. Here we survey some ofthe major drugs in use today.

Disulfiram The drug disulfiram (brand name Antabuse) discourages alcohol con-sumption because the combination of the two produces a violent response consistingof nausea, headache, heart palpitations, and vomiting. In some extreme cases, com-bining disulfiram and alcohol can produce such a dramatic drop in blood pressure thatthe individual goes into shock or even dies. Although disulfiram has been used widelyin alcoholism treatment, its effectiveness is limited because many patients who want tocontinue drinking simply stop using the drug. Others stop taking the drug becausethey believe that they can remain abstinent without it. Unfortunately, many return touncontrolled drinking. Another drawback is that the drug has toxic effects in peoplewith liver disease, a frequent ailment of people who suffer from alcoholism. Little evi-dence supports the efficacy of the drug in the long run.

Antidepressants Antidepressants may help reduce cravings for cocaine followingwithdrawal. These drugs stimulate neural processes that promote feelings of pleasurederived from everyday experiences. If cocaine users can feel pleasure from non–drug-related activities, they may be less likely to return to using cocaine. However, antide-pressants have yet to produce consistent results in reducing relapse rates for cocainedependence, so it is best to withhold judgment concerning their efficacy. The antide-pressant drug bupropion (trade name Zyban) is used to blunt cravings for nicotine inmuch the same way that other antidepressants are being used to reduce cocaine crav-ings. The drug has a modest benefit in helping people quit smoking successfully(Croghan et al., 2007). Another drug, varenicline, may be more effective than bupropi-on for smoking cessation (Barclay & Vega, 2006). Several recent controlled studiesshow that varenicline produces significant benefits in aiding smokers in quitting rela-tive to placebo (Gonzales et al., 2006; Jorenby et al., 2006; Klesges, Johnson, & Somes,2006; Tonstad et al., 2006). The drug works by binding to nicotine receptors in thebrain to blunt the reward value of smoking and to prevent withdrawal symptoms.

Nicotine Replacement Therapy Most regular smokers, perhaps the great majority,are nicotine dependent. The use of nicotine replacements in the form of prescriptiongum (brand name Nicorette), transdermal (skin) patches, and nasal sprays can helpsmokers avoid unpleasant withdrawal symptoms and cravings for cigarettes (Strasser

Is the path to abstinence from smokingskin deep? Forms of nicotine replacementtherapy, such as nicotine transdermal (skin)patches and chewing gum that containsnicotine, allow people to continue to take in nicotine when they quit smoking.Although nicotine replacement therapy ismore effective than a placebo in helpingpeople quit smoking, it does not address thebehavioral components of addiction to nico-tine, such as the habit of smoking whiledrinking alcohol. For this reason, nicotinereplacement therapy may be more effective ifit is combined with behavior therapy thatfocuses on changing smoking habits.

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A widely used treatment for heroin addictioninvolves substituting another addictive drug.

❑ TRUE. Methadone, a synthetic narcotic, iswidely used in treating heroin addiction.✓


naltrexone A drug that blocks the highfrom alcohol as well as from opiates.

methadone An artificial narcotic that isused to help people who are addicted toheroin to abstain from it without a withdrawal syndrome.

et al., 2005; Shiffman et al., 2002). After quitting smoking, ex-smokers can graduallywean themselves from the nicotine replacement. Evidence supports the therapeuticbenefits of nicotine replacement therapy, although men seem to benefit more fromtreatment than women (Cepeda-Benito, Reynoso, & Erath, 2004; Strasser et al., 2005).

Although nicotine replacement can help quell the physiological components ofwithdrawal, it has no effect on the behavioral patterns of addiction, such as the habitof smoking while drinking alcohol or socializing. As a result, nicotine replacement maybe ineffective in promoting long-term changes unless it is combined with behavioraltherapy that focuses on fostering adaptive behavioral changes.

Methadone Maintenance Programs Methadone is a synthetic opiate that bluntscravings for heroin and helps curb the unpleasant symptoms that accompany with-drawal. Because methadone in normal doses does not produce a high or leave the userfeeling drugged, it can help heroin addicts hold jobs and get their lives back on track(Schwartz et al., 2006). However, like other opioids, methadone is highly addictive. Forthis reason, people treated with methadone are, in effect, substituting dependence onone drug for dependence on another. Yet because most methadone programs are pub-licly financed, they relieve people addicted to heroin of the need to engage in criminalactivity to support their drug habit. Methadone programs need to be strictly moni-tored because overdoses can be lethal, and the drug can become abused as a street drug(Belluck, 2003). Some 200,000 heroin addicts in the United States participate inmethadone programs (Markel, 2002).

Since the introduction of methadone treatment, the annual death rate from opioiddependence declined from 21 per 1,000 to 13 per 1,000 (Krantz & Mehler, 2004). Onefrequent criticism of methadone treatment is that many participants continue to take thedrug indefinitely, potentially even for a lifetime, rather than be weaned from it. However,proponents of methadone treatment point out that the measure of success should bewhether people are able to take care of themselves and their families and act responsibly,not how long they continue to receive treatment (Marion, 2005). Even so, not everyonesucceeds in treatment. Some patients turn to other drugs, such as cocaine, to get high orreturn to using heroin. Others drop out of methadone programs.

Still another synthetic opiate drug that is chemically similar to morphine,buprenorphine, blocks withdrawal symptoms and cravings without producing astrong narcotic high (Fiellin et al., 2006). Many treatment providers preferbuprenorphine to methadone because it produces less of a sedative effective and canbe taken in pill form only three times a week, whereas methadone is given in liquidform daily. Another synthetic antiopiate, levomethadyl, also lasts longer thanmethadone and can be dispensed three times a week (Krantz & Mehler, 2004). Formaximum effectiveness, pharmacotherapy with methadone or similar drugs shouldbe combined with psychological counseling and psychosocial rehabilitation (P.G.O’Connor, 2000; E. O’Connor, 2001a).

Naltrexone Naltrexone is a drug that blocks the high produced by alcohol and byopioids, such as heroin. The drug doesn’t prevent the person from taking a drink orusing heroin, but seems to blunt cravings for these drugs. Evidence shows that nal-trexone and similar drugs are useful in treating alcohol and opiate dependence (Antonet al., 2006; Comer et al., 2006; Garbutt et al, 2005a, 2005b; Kranzler, 2006). By block-ing the pleasure produced by alcohol, the drug can help break the vicious cycle inwhich one drink creates a desire for another, leading to episodes of binge drinking.

A nagging problem with drugs such as naltrexone, disulfiram, and methadone isthat people with substance abuse problems may simply stop using them and return totheir substance-abusing behavior. Nor do such drugs provide alternative sources ofpositive reinforcement that can replace the pleasurable states produced by drugs ofabuse. These drugs are effective only in the context of a broader treatment programconsisting of psychological counseling and life-skills components, such as job training,and stress-management training. These treatments provide people with the skills theyneed to embark on a life in the mainstream culture and to find drug-free outlets forcoping with stress (Fouquereau et al., 2003; Miller & Brown, 1997).


Culturally Sensitive Treatment of AlcoholismMembers of ethnic minority groups may resist traditional treatment approachesbecause they feel excluded from full participation in society. Native American women,for example, tend to respond less favorably to traditional alcoholism counseling thanWhite women (Rogan, 1986). Hurlburt and Gade (1984) attribute this difference to theresistance of Native American women to “White man’s” authority. They suggest thatNative American counselors might be more successful in overcoming this resistance.

The use of counselors from the client’s own ethnic group is an example of a culturallysensitive treatment approach. Culturally sensitive programs address all facets of the humanbeing, including racial and cultural identity, that nurture pride and help people resist thetemptation to cope with stress through chemicals (Rogan, 1986). Culturally sensitivetreatment approaches have been extended to other forms of drug dependence, includingprograms for smoking cessation (Nevid & Javier, 1997; Nevid, Javier, & Moulton, 1996).

Treatment providers may also be more successful if they recognize and incorporateindigenous forms of healing into treatment. For example, spirituality is an importantaspect of traditional Native American culture, and spiritualists have played importantroles as natural healers. Seeking the assistance of a spiritualist may improve the coun-seling relationship. Likewise, given the importance of the church in African Americanand Hispanic American cultures, counselors working with people with alcohol use dis-orders from these groups may be more successful when they draw on clergy andchurch members as resources.

Nonprofessional Support GroupsDespite the complexity of the factors contributing to substance abuse and dependence,these problems are frequently handled by laypeople or nonprofessionals. Such peopleoften have or had the same problems themselves. For example, self-help group meetingsare sponsored by organizations such as Alcoholics Anonymous, Narcotics Anonymous,and Cocaine Anonymous. These groups promote abstinence and provide members anopportunity to discuss their feelings and experiences in a supportive group setting. Moreexperienced group members (sponsors) support newer members during periods of crisisor potential relapse. The meetings are sustained by nominal voluntary contributions.

The most widely used nonprofessional program, Alcoholics Anonymous (AA), isbased on the belief that alcoholism is a disease, not a sin. The AA philosophy holds thatthat people suffering from alcoholism will never be cured, regardless of how long theyabstain from alcohol, rather, people with alcoholism who remain “clean and sober” areseen as “recovering alcoholics.” It is also assumed that people who suffer from alco-holism cannot control their drinking and need help to stop drinking. AA has morethan 50,000 chapters in North America. AA is so deeply embedded in the conscious-ness of helping professionals that many of them automatically refer newly detoxifiedpeople to AA as the follow-up agency. About half of AA members have problems withillicit drugs as well as alcohol.

The AA experience is in part spiritual, in part group supportive, in part cognitive.AA follows a 12-step approach that focuses on accepting one’s powerlessness overalcohol and turning one’s will and life over to a higher power. This spiritual compo-nent may be helpful to some participants but distasteful to others. (Other lay organ-izations, such as Rational Recovery, adopt a nonspiritual approach.) The later stepsfocus on examining one’s character flaws, admitting one’s wrongdoings, being opento a higher power for help to overcome one’s character defects, making amends toothers, and, in step 12, bringing the AA message to other people suffering from alco-holism. Members are urged to pray or meditate to help them get in touch with theirhigher power. The meetings themselves provide group support. So does the buddy, orsponsor, system, which encourages members to call each other for support when theyfeel tempted to drink.

The success rate of AA remains in question, in large part because AA does not keeprecords of its members, but also because of an inability to conduct randomized clinical

Culturally sensitive treatment. Culturallysensitive therapy or treatment addresses allaspects of the person, including ethnic fac-tors and the nurturance of pride in one’s cul-tural identity. Ethnic pride may help peopleresist the temptation to cope with stressthrough alcohol and other substances.

S U B S TA N C E A B U S E :

Therapist LouiseRoberts“You try to make sense out of anaddiction that doesn’t make sense.”

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trials in AA settings. However, we do have evidence that participation in AA is linkedto lower frequency and intensity of drinking (Ferri et al., 2006). However, many peopledrop out of AA, as well as from other treatment programs. People who are more likelyto do well with AA tend to be those who make a commitment to abstinence, whoexpress intentions to avoid high-risk situations associated with alcohol use, and whostay longer with the program (McKellar, Stewart, & Humphreys, 2003; Moos & Moos,2004; Morgenstern et al., 2002).

Al-Anon, begun in 1951, is a spin-off of AA that supports the families and friendsof people suffering from alcoholism. Another spin-off of AA, Alateen, provides sup-port to children whose parents have alcoholism, helping them see that they are not toblame for their parents’ drinking and are thus undeserving of the guilt they may feel.

Residential ApproachesA residential approach to treatment requires a stay in a hospital or therapeutic resi-dence. Hospitalization is recommended when substance abusers cannot exercise self-control in their usual environments, cannot tolerate withdrawal symptoms, or behaveself-destructively or dangerously. Less-costly outpatient treatment is indicated whenwithdrawal symptoms are less severe, clients are committed to changing their behav-ior, and support systems, such as families, can help clients make the transition to adrug-free lifestyle. The great majority of alcohol-dependent patients are treated on anoutpatient basis.

Most inpatient programs use an extended 28-day detoxification period. For the firstfew days, treatment focuses on helping clients with withdrawal symptoms. Then theemphasis shifts to counseling about the destructive effects of alcohol and combating dis-torted ideas or rationalizations. Consistent with the disease model, abstinence is the goal.

Most people with alcohol use disorders do not require hospitalization. A classicreview article showed that outpatient and inpatient programs achieved about the samerelapse rates (Miller & Hester, 1986). However, because medical insurance does notalways cover outpatient treatment, many people who might benefit from outpatienttreatment admit themselves for inpatient treatment instead.

A number of residential therapeutic communities are also in use. Some have part-or full-time professional staffs. Others are run entirely by laypeople. Residents areexpected to remain free of drugs and take responsibility for their actions. They areoften challenged to take responsibility for themselves and to acknowledge the damagecaused by their drug abuse. They share their life experiences to help one anotherdevelop productive ways of handling stress.

As with AA, we lack evidence from controlled studies demonstrating the efficacy ofresidential-treatment programs. Also like AA, therapeutic communities have highnumbers of early dropouts. Moreover, many residents relapse upon returning to theworld outside.

Psychodynamic ApproachesPsychoanalysts view substance abuse and dependence as symptoms of conflicts rootedin childhood experiences. The therapist attempts to resolve the underlying conflicts,assuming that abusive behavior will then subside as the client seeks more mature formsof gratification. Although there are many successful psychodynamic case studies ofpeople with substance abuse problems, there is a dearth of controlled and replicableresearch studies. The effectiveness of psychodynamic methods for treating substanceabuse and dependence thus remains unsubstantiated.

Behavioral ApproachesBehavioral approaches to treating substance abuse and dependence focus on modifyingabusive and dependent behavior patterns. The key question to behaviorally orientedtherapists is not whether substance abuse and dependence are diseases but whetherabusers can learn to change their behavior when they are faced with temptation.


Self-Control Strategies Self-control training helps abusers develop skills they canuse to change their abusive behavior. Behavior therapists focus on three components—the “ABCs”— of substance abuse:

1. The antecedent cues or stimuli (As) that prompt or trigger abuse2. The abusive behaviors (Bs) themselves3. The reinforcing or punishing consequences (Cs) that maintain or discourage abuse

Table 9.2 shows the kinds of strategies used to modify the ABCs of substance abuse.

T A B L E 9 . 2

Self-Control Strategies for Modifying the “ABCs” of Substance Abuse

1. Controlling the As (Antecedents) of Substance Abuse

People who abuse or become dependent on psychoactive substances become conditioned to a wide range of external (environmental) andinternal stimuli (bodily states). They may begin to break these stimulus-response connections by:• Removing drinking and smoking paraphernalia from the home—including all alcoholic beverages, beer mugs, carafes, ashtrays, matches,

cigarette packs, lighters, etc.• Restricting the stimulus environment in which drinking or smoking is permitted by using, the substance only in a stimulus-deprived area of

their homes, such as the garage, bathroom, or basement. All stimuli that might be connected to using the substance are removed from thisarea—e.g., there is no TV, reading materials, radio, or telephone. In this way, substance abuse becomes detached from many controllingstimuli.

• Not socializing with others with substance abuse problems, by avoiding situations linked to abuse—bars, the street, bowling alleys, etc.• Frequenting substance-free environments—lectures or concerts, a gym, museums, evening classes; and by socializing with nonabusers,

eating in restaurants without liquor licenses.• Managing the internal triggers for abuse. This can be done by practicing self-relaxation or meditation and not taking the substance when

tense; by expressing angry feelings by writing them down or self-assertion, not by taking the substance; by seeking counseling not alcohol,pills, or cigarettes, for prolonged feelings of depression.

2. Controlling the Bs (Behaviors) of Substance Abuse

People can prevent and interrupt substance abuse by:• Using response prevention—breaking abusive habits by physically preventing them from occurring or making them more difficult (e.g., by

not bringing alcohol home or keeping cigarettes in the car).• Using competing responses when tempted; by being prepared to handle substance-related situations with appropriate ammunition—mints,

sugarless chewing gum, etc.; by taking a bath or shower, walking the dog, walking around the block, taking a drive, calling a friend, spendingtime in a substance-free environment, practicing meditation or relaxation, or exercising when tempted, rather than using the substance.

• Making abuse more laborious—buying one can of beer at a time; storing matches, ashtrays, and cigarettes far apart; wrapping cigarettes infoil to make smoking more cumbersome; pausing for 10 minutes when struck by the urge to drink, smoke, or use another substance andasking oneself, “Do I really need this one?”

3. Controlling the Cs (Consequences) of Substance Abuse

Substance abuse has immediate positive consequences such as pleasure, relief from anxiety and withdrawal symptoms, and stimulation. People can counter these intrinsic rewards and alter the balance of power in favor of nonabuse by:• Rewarding themselves for nonabuse and punishing themselves for abuse.• Switching to brands of beer and cigarettes they don’t like.• Setting gradual substance-reduction schedules and rewarding themselves for sticking to them.• Punishing themselves for failing to meet substance-reduction goals. People with substance abuse problems can assess themselves,

say, 10 cents for each slip and donate the cash to an unpalatable cause, such as a brother-in-law’s birthday present.• Rehearsing motivating thoughts or self-statements—such as writing reasons for quitting smoking on index cards. For example:

• Each day I don’t smoke adds another day to my life.• Quitting smoking will help me breathe deeply again.• Foods will smell and taste better when I quit smoking.• Think how much money I’ll save by not smoking.• Think how much cleaner my teeth and fingers will be by not smoking.• I’ll be proud to tell others that I kicked the habit.• My lungs will become clearer each and every day I don’t smoke.

Smokers can carry a list of 20 to 25 such statements and read several of them at various times throughout the day. They can become parts of one’sdaily routine, a constant reminder of one’s goals.

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Contingency Management Programs Learning theorists believe that our behavior isshaped by rewards and punishments. Consider how virtually everything you do, fromattending class to stopping at red lights to working for a paycheck, is influenced by the flowof reinforcements or rewards (money, praise, approval) and punishments (traffic tickets,rebukes). Contingency management (CM) programs provide reinforcements (rewards)contingent on performing desirable behaviors, such as producing drug-negative urinesamples (Petry et al., 2005; Poling et al., 2006; Roll et al., 2006). In one example, one groupof patients had the opportunity to draw from a bowl and win monetary rewards or prizemoney (rewards) ranging from $1 to $100 in value (Petry & Martin, 2002). The monetaryreward was contingent on submitting clean urine samples for cocaine and opioids. Onaverage, the contingency management (reward) group achieved longer periods of contin-ual abstinence than the standard methadone treatment group. Investigators are findingthat even modest rewards for abstinence can help improve therapeutic outcomes in treat-ing substance abusers (Higgins, Heil, & Lussier, 2004; Higgins, 2006).

Aversive Conditioning In aversive conditioning, painful or aversive stimuli are pairedwith substance abuse or abuse-related stimuli to condition a negative emotional responseto drug-related stimuli. In the case of problem drinking, tasting alcoholic beverages isusually paired with drugs that cause nausea and vomiting or with electric shock. As aconsequence, alcohol may come to elicit an unpleasant emotional or physical reaction.Unfortunately, aversive conditioning effects are often temporary and fail to generalize toreal-life settings in which aversive stimuli are no longer administered. However, it maybe useful as a treatment component in a broader-based treatment program.

Social Skills Training Social skills training helps people develop effective interper-sonal responses in social situations that prompt substance abuse. Assertiveness training,for example, may be used to train alcohol abusers to fend off social pressures to drink.Behavioral marital therapy seeks to improve marital communication and problem-solving skills with the goal of relieving marital stresses that can trigger abuse. Couplesmay learn how to use written behavioral contracts. For example, the person with a sub-stance abuse problem might agree to abstain from drinking or to take Antabuse, whilethe spouse agrees to refrain from commenting on past drinking and the probability offuture lapses. Evidence suggests that social skills training and behavioral marital ther-apy are useful in treating alcoholism (Finney & Monahan, 1996; O’Farrell et al., 1996).

Controlled Drinking: A Viable Goal? According to the disease model of alco-holism, people who suffer from the disease who have just one drink will lose controland go on a binge. Some professionals argue that behavior modification self-controltechniques can teach many people with alcohol abuse or dependence to engage incontrolled drinking—to have a drink or two without necessarily falling off the wagon(Sobell & Sobell, 1973a, 1973b, 1984). This contention remains controversial. The pro-ponents of the disease model of alcoholism, who wield considerable political strength,strongly oppose attempts to teach controlled social drinking.

Controlled drinking programs may represent a pathway to abstinence for peoplewho would not otherwise enter abstinence-only treatment programs (Marlatt et al.,1993). That is, a controlled drinking program can be a first step toward giving updrinking completely. By offering moderation as a treatment goal, controlled drinkingprograms may reach many people who refuse to participate in abstinence-only treat-ment programs (Marlatt et al., 1993). In the accompanying Controversies in AbnormalPsychology, Mark and Linda Sobell speak about what it was like to be in the eye of thestorm of controversy over the issue of controlled drinking.

Relapse-Prevention TrainingThe word relapse derives from Latin roots meaning “to slide back.” Between 50% to 90% ofpeople who are successfully treated for substance abuse problems eventually relapse (Leary,1996). Because of the prevalence of relapse, cognitive-behavioral therapists have devised anumber of methods referred to as relapse-prevention training. This training is designed tohelp substance abusers identify high-risk situations and learn effective coping for handling


these situations without turning to alcohol or drugs skills (Witkiewicz & Marlatt, 2004).High-risk situations include negative mood states, such as depression, anger, or anxiety;interpersonal conflict (e.g., marital problems or conflicts with employers); and socially con-ducive situations such as “the guys getting together” (Chung & Maisto, 2006). Participantslearn to cope with these situations, for example, by learning relaxation skills to counter anx-iety and by learning to resist social pressures to drink. They also learn to avoid practices thatmight prompt a relapse, such as keeping alcohol on hand for friends.

Relapse prevention training also focuses on preventing lapses from turning into full-blown relapses. Clients learn about the importance of their interpretations of any lapses or

CONTROVERSIES IN ABNORMAL PSYCHOLOGY

In the Eye of the Storm: The Controlled Drinking Controversy

Mark B. Sobell, Ph.D., ABPP, is Professor at the Center for Psychological Studies at Nova Southeastern Universityand Past-Editor of the Journal of Consulting and ClinicalPsychology of the American Psychological Association.

Linda Sobell, Ph.D., ABPP, is Professor and AssociateDirector of Clinical Training at the Center for Psychologi-cal Studies at Nova Southeastern University and Past-President of the Association for Advancement of BehaviorTherapy and of the Society of Clinical Psychology,American Psychological Association.

Why did the attack happen? In our published response to the attack(Sobell & Sobell, 1984) we interpreted what had occurred as a reflection of ascientific revolution. The alcohol field’s prevailing view that abstinence wasthe only legitimate treatment goal was seriously threatened, and it wasdefended at all costs. Our accusers’ objective, as stated in media interviews,was to expunge our work from the literature. Although this did not occur, itwas clear that those pursuing moderate-drinking research did so at their ownprofessional peril.

Replication is at the core of the scientific process. In the interveningyears between the attack and now, many studies have demonstrated thatlow-risk or moderate drinking can be achieved in treating many problemdrinkers (persons with low- to moderate-severity alcohol problems) (Sobell &Sobell, 1995). Research also shows that even chronic alcohol abusers treatedwith behavior therapy and a moderate drinking goal did better than controlpatients who were treated in a traditional abstinence-oriented program(Caddy et al., 1978; Sobell & Sobell, 1973a, 1973b, 1976). That’s not to saythat chronic alcohol abusers treated in moderate-drinking programs are prob-lem free. Rather, we think of the outcomes of these programs in terms ofharm reduction, meaning that participants suffer fewer negative consequencesthan control patients treated in traditional abstinence programs. An importantlegacy of our work was that it raised serious questions about the efficacy oftraditional treatments, questions that remain largely unanswered.

Critical Thinking• Do you believe that chronic alcohol abusers can learn to drink responsi-

bly? Why or why not?• What is the basis for determining when alcohol use becomes abuse or

dependence? Have you or someone you know crossed the line betweenuse and abuse?

MARK AND LINDA SOBELL, IN THEIR OWN WORDSOur careers began before we had our doctorates. In 1969, we began summerjobs at Patton State Hospital (CA). Within weeks, that evolved into anunusual opportunity to conduct federally funded alcohol research. We were inthe right place at the right time. The field of behavioral therapy was in itsinfancy and witnessing some exciting advances. The scientific study of alco-hol problems was also in its infancy. Early research at the hospital haddemonstrated that severely dependent alcohol abusers could limit theirdrinking (e.g., drink just 1 to 3 drinks) in a supervised hospital environment.Furthermore, we found several published studies that suggested that somealcohol abusers could learn to drink moderately without losing control oftheir drinking. This led us to conduct our highly controversial study,“Individualized Behavior Therapy for Alcoholics” (Sobell & Sobell, 1973b).

Patients were evaluated for their eligibility for a moderate drinking goal,and those who qualified were randomly assigned either to an inpatient-based,broad-spectrum behavioral treatment program that had a controlled drinkinggoal or to a control group (i.e., standard hospital treatment with an abstinencegoal). Those ineligible for a moderation goal were randomized to the behavioraltreatment or the standard hospital treatment, both with an abstinence goal.Follow-up was conducted for 2 years (Sobell & Sobell, 1976); an independentdouble-blind third-year follow-up was also conducted (Caddy, Addington, &Perkins, 1978). Although both experimental groups had superior outcomes rela-tive to their control groups, the moderate drinking group’s superiority wasmaintained over a 3-year period, whereas differences between the abstinencegoal groups were no longer significant after the 1-year follow-up. The moderatedrinking group had more than twice as many “functioning well” days (i.e., notdrinking or drinking just a few drinks) and twice as many abstinent days astheir control group. The findings of our rigorous study challenged, as no otherstudy had, the traditional view that only abstinence goals were effective.

In 1982 our careers almost ended when the journal Science published anarticle challenging the study’s findings. Although the allegations were veiled inthe article, in media interviews the authors claimed we had falsified our data(Marlatt, 1983). Fortunately, we had retained our original data (e.g., drivers’records, arrest records, tape-recorded interviews with clients). When the allega-tions were released, they triggered a media frenzy tantamount to a witch hunt.Several investigations eventually vindicated us. The first, a blue ribbon com-mittee in Toronto, where we were employed, examined our data and concluded,“The Committee finds the Sobell’s published data to be accurate, and concludesunequivocally that there is no evidence of fraud, deception, dishonesty orunethical behavior” (Dickens et al., 1982, p. 9). Shortly thereafter, there was acongressional investigation followed by an investigation by the NationalInstitutes of Health and two ethics investigations by the AmericanPsychological Association. In all instances, we were vindicated, as no investigation found evidence of fraud or deception. Nevertheless, theallegations traveled fast among traditional alcohol treatment programs and thepublic, leading many to the unquestioning assumption that controlled drinkinghad been “debunked.” Unfortunately, because vindications are not as newswor-thy as are allegations of fraud, many still are not aware of our vindication.

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slips that may occur, such as smoking a first cigarette or taking a first drink following quit-ting. They are taught not to overreact to a lapse by changing how they think about lapses.For example, they learn that people who lapse are more likely to relapse if they attributetheir slip to personal weakness, and experience shame and guilt, than if they attribute theslip to an external or transient event. For example, consider a skater who slips on the ice(Marlatt & Gordon, 1985). Whether the skater gets back up and continues to performdepends largely on whether the skater sees the slip as an isolated and correctable event oras a sign of complete failure. Because lapses in ex-smokers often occur in response to with-drawal symptoms, it is important to help smokers develop ways of coping with thesesymptoms without resuming smoking (Piasecki et al., 2003). Participants in relapse-prevention training programs learn to view lapses as temporary setbacks that provideopportunities to learn what kinds of situations lead to temptation and to either avoidthem or learn to cope with them. If they can learn to think, “Okay, I had a slip, but thatdoesn’t mean all is lost unless I believe it is,” they are less likely to relapse.

All in all, efforts to treat people with substance abuse and dependence problems havehad mixed results at best. Many abusers really do not want to discontinue use of thesesubstances, although they would prefer, if possible, to avoid their negative consequences.Yet many treatment approaches, including 12-step and cognitive-behavioral approaches,can work well when they are well delivered and when individuals desire change (Miller& Brown, 1997; Moos & Moos, 2005; Project MATCH Research Group, 1997).

Effective treatment programs include multiple approaches that match the needs ofsubstance abusers and the range of problems with which they often present, includingco-occurring psychiatric problems, such as depression and personality disorders(Grant et al., 2004; Nunes & Levin, 2004). Comorbidity (co-occurrence) of substanceuse disorders and other psychological disorders, especially mood disorders, havebecome the rule in treatment facilities rather than the exception (Morris, Stewart, &Ham, 2005; Quello, Brady, & Sonne, 2005). Not surprisingly, drug abuse treatment isoften complicated by the presence of other serious psychological problems. As notedin this first-person narrative, the co-occurrence of substance abuse greatly complicatesthe treatment of other psychological disorders.

“Surely They Can’t Mean Beer!”Six years ago, at the age of 24, I was diagnosed with manic-depression. Learning to live withthis mental illness has been extremely difficult. I have been in a series of different hospitals.After suffering a manic episode and being hospitalized, I would attempt to recover, but within90 days or so I would end up in a hospital again. I never really had a fair chance of recoveringfrom my manic depression because I had been suffering from alcoholism, another illness, at thesame time. The alcoholism wasn’t being treated. After being discharged from hospitals I wouldresume drinking and then within a matter of a few months I would be back in another hospitalhaving suffered another manic episode. It was strongly suggested to me when I was first diag-nosed with manic depression that I should stop drinking. I remember my response clearly.“Surely they can’t mean beer!”

My drinking escalated when I first joined a program known as Alcoholics Anonymous. Duringthose years I was in complete denial of what alcohol was doing to the chemical make-up of mybody. I drank in order to suppress the negative feelings of mania and depression. I had to livewith double trouble and the more I drank the sicker I became. I simply refused to address myalcoholism problem because alcohol had become my best friend. Denial runs deep!

It took a family crisis where my parents told me they would no longer support me emotion-ally or financially if I ended up in the hospital and alcohol was involved. This scared me to thepoint where I called Alcoholics Anonymous and began attending AA meetings. It takes time butAA seems to be working for me. I have arrested my drinking problem through total abstinence.Now the medication I take has a chance to work the way it was intended. Stopping drinkingalcohol is only part of the solution. For me, working with doctors who understand my manicdepressive illness and getting the proper medication is the key to a successful recovery.

—From Adam White, reprinted with permission of New York City Voices


Although effective treatment programs are available, only a minority of people withalcohol dependence ever receive treatment, even when we define treatment broadlyenough to include AA (Kranzler, 2006). A recent study in Canada echoed these find-ings. In a sample of more than 1,000 people in Ontario, Canada, with alcohol abuse ordependence disorders, only about one in three had ever received any treatment fortheir disorder (Cunningham & Breslin, 2004). Clearly more needs to be done to helppeople whose use of alcohol and other drugs puts them at risk.

In the case of inner-city youth who have become trapped within a milieu of streetdrugs and hopelessness, culturally sensitive drug counseling and job training wouldbe of considerable benefit in helping them assume more productive social roles. Thechallenge is clear: to develop cost-effective ways of helping people recognize the neg-ative effects of substances and forgo the powerful and immediate reinforcements theyprovide.

Substance abuse and dependence are complex patterns of behavior that reflect the interplay ofbiological, psychological, and environmental factors. These problems are best approached

by investigating the distinctive constellation of factors that apply to each individual case.No single model or set of factors will explain each case, which is why we need to under-stand each individual’s unique characteristics and personal history and direct treatment

accordingly. The accompanying Concept Map for Abnormal Psychology illustrates key causalfactors and major treatment approaches, along with a conceptual model for understanding how thesecausal factors interact.

Genetic factors can create a predisposition or diathesis for substance abuse and dependence. Somepeople may be born with a greater tolerance for alcohol, which can make it difficult for them toregulate use of alcohol—to know “when to say when.” Others have genetic tendencies that can leadthem to become unusually tense or anxious. Perhaps they turn to alcohol or other drugs to quell theirnervousness. Genetic predispositions can interact with environmental factors to increase the poten-tial for drug abuse and dependence—factors such as pressure from peers to use drugs, parentalmodeling of excessive drinking or drug use, and family disruption that results in a lack of effectiveguidance or support. Cognitive factors, especially positive drug expectancies (e.g., beliefs that usingdrugs will enhance one’s social skills or sexual prowess), raise the potential for alcohol or drug useproblems. In adolescence and adulthood, these positive expectations, together with social pressuresand a lack of cultural constraints, affect the young person’s decision to begin using drugs and to con-tinue to use them. Patterns of regular use can lead to abuse and dependence. Once physiologicaldependence develops, people use the substance to avoid withdrawal symptoms.

Sociocultural and biological factors are also included in this matrix of factors: the availability ofalcohol and other drugs; the presence or absence of cultural constraints; the glamorizing of drug usein popular media; and genetic tendencies (such as among Asians) to “flush” more readily followingalcohol intake (Luczak, Glatt, & Wall, 2006).

Learning factors also play important roles. Drug use may be positively reinforced by pleasurableeffects (mediated perhaps by release of dopamine in the brain or by activation of endorphin recep-tors). It may also be negatively reinforced by the reduction of tension and anxiety that depressantdrugs such as alcohol, heroin, and tranquilizers can produce. In a sad but ironic twist, people whobecome dependent on drugs may continue to use them solely because of the relief from withdrawalsymptoms and cravings they encounter when they go without the drug.

SUMMING UP

Classification of Substance-Related DisordersHow does the DSM distinguish between substance abusedisorders and substance dependence disorders? According tothe DSM, a substance abuse disorder is a pattern of recurrentuse of a substance that repeatedly leads to damaging consequences.Substance dependence disorders involve impaired control overuse of a substance and often include features of physiological

dependence on the substance, as manifest by the development oftolerance or an abstinence syndrome.

What do we mean by the terms “addiction” and “psycholog-ical dependence”? Although different people use the termaddiction differently, it is used here to refer to the habitual orcompulsive use of a substance combined with the developmentof physiological dependence. Psychological dependence is the

326 Chapter 9

compulsive use of a substance, with or without the developmentof physiological dependence.

Drugs of AbuseWhat are depressants? Depressants are drugs that depressor slow down nervous system activity. They include alcohol,sedatives and minor tranquilizers, and opioids. Their effectsinclude intoxication, impaired coordination, slurred speech,and impaired intellectual functioning. Chronic alcohol abuseis linked to alcohol-induced persisting amnestic disorder(Korsakoff ’s syndrome), cirrhosis of the liver, fetal alcohol syn-drome, and other physical health problems. Barbiturates aredepressants or sedatives that have been used medically for short-term relief of anxiety and treatment of epilepsy, among otheruses. Opioids such as morphine and heroin are derived from theopium poppy. Others are synthesized. Opioids are used med-ically for relief of pain and are strongly addictive.

What are stimulants? Stimulants increase the activity of thecentral nervous system. Amphetamines and cocaine are stimu-lants that increase the availability of neurotransmitters in thebrain, leading to heightened states of arousal and pleasurablefeelings. High doses can produce psychotic reactions that mimicfeatures of paranoid schizophrenia. Habitual cocaine use canlead to a variety of health problems, and an overdose can causesudden death. Repeated use of nicotine, a mild stimulant foundin cigarette smoking, leads to physiological dependence.

What are hallucinogens? Hallucinogens are drugs that distortsensory perceptions and can induce hallucinations. Theyinclude LSD, psilocybin, and mescaline. Other drugs with simi-lar effects are cannabis (marijuana) and phencyclidine (PCP).Althoug these drugs may not lead to physiological dependence,psychological dependence may occur.

Theoretical PerspectivesHow do the major theoretical perspectives view the causes ofsubstance abuse and dependence? The biological perspective

focuses on uncovering the biological pathways that may explainmechanisms of physiological dependence. The biological per-spective spawns the disease model, which posits that alcoholismand other forms of substance dependence are disease processes.Learning perspectives view substance abuse disorders as learnedpatterns of behavior, with roles for classical and operant condi-tioning and observational learning. Cognitive perspectives focuson roles of attitudes, beliefs, and expectancies in accounting forsubstance use and abuse. Sociocultural perspectives emphasizethe cultural, group, and social factors that underlie drug-usepatterns, including the role of peer pressure in determiningadolescent drug use. Psychodynamic theorists view problems ofsubstance abuse, such as excessive drinking and habitual smok-ing, as signs of an oral fixation.

Treatment of Substance Abuse and DependenceWhat treatment approaches are used to help people over-come problems of substance abuse and dependence?Biological approaches to substance abuse disorders includedetoxification; the use of drugs such as disulfiram, methadone,naltrexone, and antidepressants; and nicotine replacementtherapy. Residential treatment approaches include hospitalsand therapeutic residences. Nonprofessional support groups,such as Alcoholics Anonymous, promote abstinence within asupportive group setting. Psychodynamic therapists focus onuncovering the inner conflicts originating in childhood thatthey believe lie at the root of substance abuse problems.Behavior therapists focus on helping people with substance-related problems change problem behaviors through suchtechniques as self-control training, aversive conditioning, andskills training approaches. Regardless of the initial success of atreatment technique, relapse remains a pressing problem intreating people with substance abuse problems. Relapse-prevention training employs cognitive-behavioral techniquesto help recovering substance abusers cope with high-risk situ-ations and prevent lapses from becoming relapses by inter-preting lapses in less damaging ways.

KEY TERMSsubstance-induced disorders (p. 291)intoxication (p. 292)substance use disorders (p. 292)substance abuse (p. 292)substance dependence (p. 292)tolerance (p. 293)withdrawal syndrome (p. 293)addiction (p. 294)physiological dependence (p. 294)

psychological dependence (p. 295)depressant (p. 296)alcoholism (p. 297)barbiturates (p. 303)narcotics (p. 303)endorphins (p. 304)morphine (p. 304)heroin (p. 304)stimulants (p. 305)

amphetamines (p. 305)amphetamine psychosis (p. 305)cocaine (p. 305)crack (p. 306)hallucinogens (p. 308)marijuana (p. 309)detoxification (p. 317)methadone (p. 318)naltrexone (p. 318)


KEY FOR “ARE YOU HOOKED?” QUESTIONNAIREAny yes answer suggests you may be dependent on alcohol. If you have answered any ofthese questions in the affirmative, we suggest you seriously examine what your drinkingmeans to you.

MEDIA TOOLSA variety of digital and online learning tools are available toenrich your learning experience and help you succeed in thecourse. These resources include:

• MYPSYCHLAB, an online learning system for your course in abnor-mal psychology that allows you to test your mastery of conceptsin the book by using chapter-by-chapter diagnostic tests. Resultsfrom the diagnostic tests help you build a customized study plan.To access MyPsychLab, visit www.prenhall.com/mypsychlab andfollow the instructions on the site.

• “SPEAKING OUT” PATIENT INTERVIEWS, a set of video caseexamples of actual patients you can access on the companion

CD-ROM included with the text. Icons in the margins of thechapter highlight the video case examples included on theCD-ROM.

• COMPANION WEB SITE, an online study center that offerscomputer-scored quizzes you can use to test your knowledge,along with other study tools and links to related sites toenhance your learning of abnormal psychology. To access thecompanion web site, visit www.prenhall.com/nevid and usethe various tabs and links on the site to access these learningresources.

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A Biopsychosocial Model of Substance Abuse and Dependence

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